We face both a generational opportunity and a challenging conversation, as the California Advancing and Innovating Medi-Cal (CalAIM) initiative moves forward with the important step of DHCS seeking federal approval of the 1115 demonstration amendment and 1915(b) waiver. The welcome improvements realized by the CalAIM process appear to have been eroded in DHCS’ current 1915(b) waiver proposal by a set of contradictory requirements, new screening obligations, lack of clarity, and a potentially dangerous misinterpretation of ACEs science.

As outlined below, the proposal is a dichotomy of “saying yes, but doing no,” and therefore does not meet CCT’s requirements for reimagining the social-emotional wellbeing of California’s most vulnerable children as detailed in our Framework for Solutions.

These are hard words to write, as there is real promise in the work DHCS and engaged stakeholders have put forward. And we gratefully accept incremental change while we await the more fundamental changes our children and families require. Presumptive eligibility for children in foster care, for children experiencing homelessness, and for children exposed to toxic stress is an advancement to opening up access and lowering the bar to entry into the specialty mental health system.

However, the requirement of adversity screening “scores” and a yet-to-be-determined level of care screening mechanism between delivery systems appears to create new burdens, requirements, and obligations that reinforce the medical model, do not provide a clear path to improving access or quality, and most importantly do not increase the agency and power of beneficiaries.

DHCS leadership has affirmed their commitment to these principles and advised us that further clarification of these issues is forthcoming—and we do want to emphasize that we feel aligned and supportive of new state leadership. But the waiver as currently written runs the risk of being misinterpreted by mental health plans and managed care organizations and does not go far enough in redefining behavioral health as an essential support for healthy development, not a response to pathology.

Three ways the CalAIM 1915(b) waiver proposal fails to meet the mental health needs of vulnerable children:

In October 2019, the initial CalAIM proposal offered real and substantive changes for specialty mental health. It was far and away the most ambitious and courageous action by DHCS on mental health in more than 20 years. However, the 1915(b) waiver erodes these advancements with the following series of contradicting requirements.

• Medical necessity: Advocacy efforts by CCT and partners contributed to a change in the state’s definition of medical necessity, allowing children to receive a specified amount of therapy without a diagnosis, as outlined in the “game-changing” Family Therapy Benefit Guide. However, this significant step forward is eroded in the current proposal by requiring a high trauma score as a mandate for services—basically pathologizing adversity and disregarding the wishes and wisdom of beneficiaries to determine their own needs.

"If I refer a child with a heart murmur to a cardiologist, the visit would be authorized in a timely manner. I do not have to do an EKG or exercise testing or 4-limb blood pressures to prove that they need to see the cardiologist; the health plan doesn't require a phone assessment before authorizing the appointment. With behavioral health, we should have easy access for children and teens to begin treatment in a timely manner. This is required by law, but somehow never implemented by DHCS. I hope that we can use this opportunity to develop a partnership with them and realize some improvements in the present waiver proposal."
- Diane Dooley, MD, MHS, FAAP, Pediatrician, and Associate Clinical Professor of Family and Community Medicine at UC San Francisco

• “No wrong door:" The goal of a child being served in the system in which they originally present their need is eroded by the level of care proposal and accompanying screening tools. The concept of a “no wrong door” means when you enter the door, you are served. It does not mean you are screened and sent elsewhere.
  
  
• Payment reform: The 1915(b) waiver proposes moving county mental health plans from a Certified Public Expenditure (CPE) methodology to Intergovernmental Transfer (IGT)—which could increase federal revenue for counties and open up the possibility of claiming against non-federal dollars already being spent in other child-serving systems. However, there are multiple unanswered questions that raise concerns and prohibit us from fully evaluating the proposal. DHCS has listened to our concerns and pledged to address them (including modeling at the local MHP level) in advance of implementation in July 2022.

Take action to turn the CalAIM promise into practice

CCT is submitting formal Response Letters with our partners that include more detailed comments and recommendations.

We urge you—allies, advocates, and philanthropic and public partners—to use the following language to submit your comments directly to DHCS, or in the feedback that you or your organization are already preparing.

Comments must be received no later than 11:59 PM (Pacific Time) on Thursday, May 6, 2021, and can be emailed to CalAIMWaiver@dhcs.ca.gov. Please indicate “CalAIM Section 1115 & 1915(b) Waiver” in the subject line of the email message.

The CalAIM 1915(b) waiver proposal does not go far enough to directly address the impact of racism on the social and emotional health of children. The proposal must be revised to:

• Resist pathologizing adversity—as evidenced by proposed tools to “screen in for a high risk score” for ongoing services. We must honor the wisdom and intelligence of low income communities to determine their own definition of medical necessity. Any positive screen, and more importantly, any request for support from a beneficiary should qualify a child for services and support.
• Fully honor the commitment to no wrong door by removing the future creation of a level of care tool and plan--or if such a tool is to be used it must only be used during the course of treatment and treatment can not be stopped or interrupted until or if there is a transition in care.
• Clarify unanswered questions about the potential risks related to moving county mental health plans from a Certified Public Expenditure (CPE) methodology to Intergovernmental Transfer (IGT).

Thank you for joining us to advocate for a CalAIM proposal that lives up to its promise to meet the mental health needs of California’s most vulnerable children.

Alex Briscoe, Principal, California Children’s Trust

Jevon Wilkes, Executive Director, California Coalition for Youth; and
Director of Youth Engagement, California Children’s Trust