‘Praying every night that someone doesn’t die’: State must fix rift with local counties | Opinion

A dispute between the state of California’s Department of Health Care Services and the counties of Sacramento and Solano could leave more than 7,000 mentally ill patients without adequate care. That can’t happen — especially not now, with so many people living and dying on our streets while experiencing mental illness.

We need to provide more care for our most vulnerable neighbors, not less.

But officials from the two counties say they have been fighting with the state for more than a year over the implementation of CalAim, a program Gov. Gavin Newsom has touted many times as a much-needed overhaul of mental health services, insured by Medi-Cal.


The stated goals of CalAim on the state website are to “improve quality outcomes, reduce health disparities and transform the delivery system through value‑based initiatives, modernization and payment reform.” Another goal of CalAim is to make the Medi-Cal system, which serves low-income residents, less confusing and more accessible to the people who need it.

But conforming to CalAim is proving to be exceedingly confusing and stressful to the counties and health providers who are expected to take on these new roles.

Ryan Quist, behavioral health services director of Sacramento County, and Debbie Vaughn, assistant director of the Department of Health and Social Services in Solano County, say the state is setting up thousands of at-risk patients for disaster. It’s all leading up to what they say is an estimated 16% increase in mental health patients in Sacramento County and a staggering 46% increase in Solano County in just one day.

“It’s just untenable, it cannot happen,” Vaughn said. “Or we’re gonna have some really, really, really, potentially bad consequences.”

Mental health patients from Sacramento and Solano Counties have been receiving care from Kaiser Permanente. But the state wants the two counties to move the patients back to county mental health plans to standardize benefits and manage care plans for patients, said Katharine Weir-Ebster, information officer for the California Department of Health Care Services, in a written statement.

The counties say they don’t have the funding to take on those services, and say they would be an approximate $52 million short without financial assistance from the state.

Leslie Napper, who lives with bipolar disorder, was a client of Sacramento County’s mental health services and now serves on the county’s Mental Health Services Act steering committee. She knows firsthand how important the bond and trust is between a doctor and a patient living with a severe mental health diagnosis.

“A caring provider would massage me into this new process that I’m going to have to accept instead of being forced into, so I have a choice,” Napper said. “(They would) help me with my discharge plan as I transition into an entirely new system. And then, hopefully, there’d be a warm hand-off. It’s during this transition process that the trust building happens. “

Without this warm hand-off, many of these patients will “languish,” Napper said.

“We know that we can — with a proper community, basic support and wraparound services — do our wellness journey,” Napper said. “We can survive in the community and we want to. (But) we need to have the system set up to receive us in order for that to happen.”

Counties don’t have capacity

The transition to CalAim has been turbulent in other parts of the state as well; a recent Cal-Matters story said that “community-based organizations that provide many of the mental health services outlined under CalAIM say they feel left out of the loop in important conversations about coming payment reforms.”

Vaughn, of Solano County, said she is frustrated and worried.

“The worst case scenario is that (all of the) individuals get sent over on one day and we have no capacity to serve them,” she said. “I’m terrified. If the state pushes this the way that they have, ... I’m going to be praying every night that someone doesn’t die.”

“Our two counties currently don’t have the funding or capacity to serve such a huge influx of patients with such serious needs,” Quist added. “It’s just sort of shocking and sort of confusing because we know that the governor has been such a champion, and has provided such leadership around behavioral health topics.”

Quist and Vaughn say that, after their push-back, Department of Health Care Services officials finally came up with a plan to help with the shortfall, but the grand solution was that Sacramento and Solano should ask the state’s 56 other counties to create a general fund out of their own behavioral health services budgets — which would only take away money from the already razor-thin budgets for programs currently operating in those areas.

Additionally, the local government process to create and run a program of this magnitude is long and complex. It requires approval from county supervisors; sending out a request for proposals; and then a county vote on which provider will be hired and what the program will look like. That all has to take place before services can begin.

As the new provider to thousands of patients, developing a relationship will be critical, Quist said, “in order for them to open up and talk to us about what their challenges are.”

Vaughn said Sacramento and Solano County administrations have been begging the state for this extra funding for years, ever since the transition was announced (the counties say it was subsequently delayed because of the pandemic, then reannounced last year, but the state disputes this.) Now, county staff can’t even begin to plan for proposals, hiring new staff or transitioning thousands of severely mentally ill patients all without the promise of a budget.

“It is disingenuous of the state to say that there’s been any real conversation when there hasn’t been any money on the table,” Vaughn said. “It’s like playing with Monopoly money. It’s completely ludicrous that the expectation is — and that the messaging from (the Department of Health Care Services) — is that we’ve had plenty of time to plan for it, (but) we can’t plan without funding.”

The state has given the counties a July 1 deadline to take on mental health patients that had been served by Kaiser. But that deadline has moved several times as the parties negotiate.

The Department of Health Care Services say they have given the counties adequate notice and as much financial support as is legally required of them, and that they have made “modifications” to “address the counties’ funding concerns.”

“Kaiser is paid approximately $22.6 million annually in capitation payments for this population across the two counties,” Weir-Ebster wrote in a statement. “Note that this $22.6 million includes federal and non-federal funds, and is not an ‘apples-to-apples’ comparison.”

Quist said he often works closely with many of the people at the department and usually finds them to be “reasonable folks.”

“But this is just absolutely confusing,” he said. “Why is nobody else as concerned as we are regarding the lives of these individuals that we’re being asked to serve and would love to serve if we had the right resources?”

Meanwhile, letters continue flying between Michelle Baass, director of the Department of Health Care Services, and the two county executives, Ann Edwards of Sacramento County and William Emlen of Solano County. With July 1 rapidly approaching, nothing has been resolved, yet more than 7,000 people with severe mental illnesses still stand to suffer greatly.

Sacramento and Solano Counties must receive broad financial and administrative support from the state of California and from the Department of Health Care Services if this transition is to be successful. Anything less is a dereliction of duty to mentally ill patients who rely on the state for their care. Thousands of lives are on the line.