In 2020 California will renew its Medicaid waiver and this revision has the potential to impact the provision of mental and behavioral health services for years to come. A Medicaid Waiver is a provision in Section 1115 of the federal Social Securities Act that allows states to provide services to residents who may not be eligible under the basic Medicaid rules. Because of this provision, states can use Medicaid funds for new or innovative programs and increase access to care for underserved groups. The current debate will define the criteria for these expanded programs and set the foundation for many of the regulations that impact practice.
There are a number of critical points being debated as a part of this reform effort, but one that is of particular interest, given its direct alignment with Unconditional Education is the discussion related to just how children can gain access to mental and behavioral health care. Under the current system, a client must receive a diagnosis of a mental health disorder in order to be “opened” or receive ongoing sessions with a therapist funded through MediCal. A diagnosis, representing a cluster of symptoms, indicates that treatment is medically necessary. While this determination of “medical necessity” seems like a clear-cut distinction, how it plays out in practice is substantially more nuanced, complex, and can have problematic consequences for both individuals and our larger system of care. Loosening the restrictions around this provision and allowing therapists to serve clients without first providing a formal diagnosis would provide an opportunity to:
Stop problems before they start.
For far too many children who have faced multiple stressors in under-resourced systems the point of diagnosis comes only after a critical level of challenge has been reached. Children are referred to care only once they are already presenting acute symptoms impacting their daily functioning and success at school. Increasing the flexibility with which therapeutic services can be provided would open new opportunities to focus on prevention and early intervention and increase access to care for families who utilize MediCal.
Reduce the stigmatization of mental health care.
Currently, diagnosis must occur early in the relationship between the client, caregiver and therapist and requires that early discussions focus on about what’s “wrong” with the child. This required entry point stands in deep contrast to what is otherwise a belief in providing a strengths-based approach to care. While sometimes the establishment of a diagnosis is a useful tool for determining course of treatment, it can also be barrier that prevents families from accessing services for fear of being labeled as “mentally ill”. Further, the criteria of a diagnosis requires a clinician to pathologize many of the normal ups and downs of wellbeing and responses to stress that families experience over time in order to provide needed support. Increased flexibility in accessing MediCal has the potential to reduce the stigmatization that can come with receiving mental health services and support the cultivation of a client’s strengths and protective factors from the start of care.
Promote equity.
Beyond the issues of accessing care above, there are problematic challenges with the establishment of a diagnosis in and of itself. There’s a growing body of research to demonstrate that poor children of color are more likely to receive diagnosis of Oppositional Defiant Disorder (ODD) and less likely to receive diagnosis of Attention Deficit Hyperactivity Disorder (ADHD) than their more affluent white peers, even when other factors, such as the prevalence of trauma, were accounted for. While similar in symptomology, these two diagnoses carry vastly different social meanings and can indicate largely different trajectories for a client’s care. Patterns of diagnosis that follow predictable and disproportionate lines across race and class indicate the ways in which unmitigated bias continue reinforce the oppressive systems that impact Medicare recipients. Reducing the emphasis on diagnosis, and instead focusing on client wellbeing, would promote a more equitable approach.
While there is still much to be determined in the development of California’s proposed waiver it is exciting to engage on this important discussion. To follow this discussion and the others that are a part of the Waiver debate follow along at MediCal: A Healthier California for All.
There are a number of critical points being debated as a part of this reform effort, but one that is of particular interest, given its direct alignment with Unconditional Education is the discussion related to just how children can gain access to mental and behavioral health care. Under the current system, a client must receive a diagnosis of a mental health disorder in order to be “opened” or receive ongoing sessions with a therapist funded through MediCal. A diagnosis, representing a cluster of symptoms, indicates that treatment is medically necessary. While this determination of “medical necessity” seems like a clear-cut distinction, how it plays out in practice is substantially more nuanced, complex, and can have problematic consequences for both individuals and our larger system of care. Loosening the restrictions around this provision and allowing therapists to serve clients without first providing a formal diagnosis would provide an opportunity to:
Stop problems before they start.
For far too many children who have faced multiple stressors in under-resourced systems the point of diagnosis comes only after a critical level of challenge has been reached. Children are referred to care only once they are already presenting acute symptoms impacting their daily functioning and success at school. Increasing the flexibility with which therapeutic services can be provided would open new opportunities to focus on prevention and early intervention and increase access to care for families who utilize MediCal.
Reduce the stigmatization of mental health care.
Currently, diagnosis must occur early in the relationship between the client, caregiver and therapist and requires that early discussions focus on about what’s “wrong” with the child. This required entry point stands in deep contrast to what is otherwise a belief in providing a strengths-based approach to care. While sometimes the establishment of a diagnosis is a useful tool for determining course of treatment, it can also be barrier that prevents families from accessing services for fear of being labeled as “mentally ill”. Further, the criteria of a diagnosis requires a clinician to pathologize many of the normal ups and downs of wellbeing and responses to stress that families experience over time in order to provide needed support. Increased flexibility in accessing MediCal has the potential to reduce the stigmatization that can come with receiving mental health services and support the cultivation of a client’s strengths and protective factors from the start of care.
Promote equity.
Beyond the issues of accessing care above, there are problematic challenges with the establishment of a diagnosis in and of itself. There’s a growing body of research to demonstrate that poor children of color are more likely to receive diagnosis of Oppositional Defiant Disorder (ODD) and less likely to receive diagnosis of Attention Deficit Hyperactivity Disorder (ADHD) than their more affluent white peers, even when other factors, such as the prevalence of trauma, were accounted for. While similar in symptomology, these two diagnoses carry vastly different social meanings and can indicate largely different trajectories for a client’s care. Patterns of diagnosis that follow predictable and disproportionate lines across race and class indicate the ways in which unmitigated bias continue reinforce the oppressive systems that impact Medicare recipients. Reducing the emphasis on diagnosis, and instead focusing on client wellbeing, would promote a more equitable approach.
While there is still much to be determined in the development of California’s proposed waiver it is exciting to engage on this important discussion. To follow this discussion and the others that are a part of the Waiver debate follow along at MediCal: A Healthier California for All.
Blog Post Written By: Robin Detterman, Executive Director of School Partnerships
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