Interview with Proposition 63 co-author Rusty Selix

Rusty Selix knows the dynamic relationship between health insurance and mental-health care. He’s executive director for California Council of Community Mental Health Agencies and Mental Health America of California and, in 2004, he co-authored Proposition 63, the Mental Health Services Act. Now, with the Affordable Care Act set to go into effect on January 1, 2014, SN&R sat down with Selix to discuss how its implementation will impact those in California afflicted with mental-health problems.

Millions of Californians are suffering from mental-health conditions but aren’t getting treatment. How is the Affordable Care Act going to impact those people?

It changes things in many ways, but the two that are most apparent to people are that it eliminates the gaps in what is covered in mental health, and it significantly closes the gaps of who has health care and if that health care will now have to include mental-health care.

Can you give an example of a particular case?

A family [with a] 23-year-old son just developed very serious schizophrenia, and we wanted to put him in programs that this provider offers. This provider is funded through the county, and the family had their 23-year-old child on … an Anthem Blue Cross plan. But it wouldn’t have mattered: All the plans are the same on this. The plan said, “We don’t provide that care.” The provider and the family and the county talked to each other, and they said, “Well, if you took the child off of your insurance … we can get that child Medi-Cal and disability benefits. And once he has that, then we can put him in that program.” That’s what they did.

If this young adult would have had a broken leg or something, they would have been able to get ongoing care. But because it was a mental condition, they weren’t able to get treatment—and then in some other cases, it often goes untreated, which then has other kinds of consequences.

That’s exactly right. In other words, what we know is that for people with a severe and disabling mental illness or a life-threatening condition … they need much more than the occasional visit to a therapist. But they don’t need to be in a hospital. And that so-called intermediate care is what health plans have not been offering for mental health. Even though, in our view, it’s always been equivalent to rehabilitative care, as you would say, after somebody broke a leg or had a major surgery on another organ of the body, they would of course need that.

But when the organ is the brain, and it’s not surgery—it’s another type of stabilization—their health plans haven’t historically made that care available.

Who will benefit most from these changes?

That’s going to affect two classes of people. The first, and the largest and the one we see the most with mental health issues, is what might be better known as street people. These are people that have no income, or very low income, and do not have dependent children and have not been determined to have a disability. They might actually have one, but they’re not in the system. These are the people the police see every day; these are the people we all see every day out on the streets, and they’re not eligible for Medi-Cal right now. …

The idea is enroll them and get them stabilized, and get them help, and get that kind of care. … Some of them may turn out to be disabled, and may meet other criteria for long-term help. But the fact is they will all get help, and they will all have full mental health and alcohol and drug treatment available to them.

For California, we have an estimated 1 million residents that will be eligible for expanded Medi-Cal.

Yes, there’s also very low-income people. It’s not just the street people, it’s people that have a marginal life, perhaps working a minimum-wage job that has no health insurance that would qualify for Medi-Cal. But the biggest mental-health need, of course, is the street people, because most of them have significant mental-health problems.

And so that’s why I mentioned them first, but certainly all of the low-income people will be eligible and will have an opportunity to get mental-health care.

There are some that say that these two changes are representing a sea change for mental health here in California.

Well, it is. There are more changes as well. I think it’s not just the low-income people that are going to be moving into Medi-Cal, but a lot of the people that will enroll in the health-benefits exchange are people who have sought health insurance in the past, didn’t have it offered by the employer, but had a pre-existing condition—and a mental illness is a very common pre-existing condition. It turns out that if you had ever seen a therapist or ever been put on an anti-depressant or other mental-health medication, you were deemed to have a pre-existing mental illness and not eligible to buy health insurance on your own.

As it becomes close to full implementation of these different components, how much bigger do you think the mental-health apparatus will become?

Well, that’s been studied, and the best guess from one of the leading experts in the country was a 20 to 30 percent increase in the amount of mental-health care that is going to be delivered in California.

There’s a lot of fear about how much it’s going to cost.

First of all, mental health as a part of total health-care costs is under 5 percent, so it’s not like it’s a significant part of the cost. The good news, and really the most exciting news, is that there are now numerous studies, [and] every one of them has proven that making sure that we give everybody all of the mental-health care they need actually lowers overall costs.

I think it’s easy to envision that down the road, five or 10 years from now, … the overall spending on mental health will go down if we are as successful as I think we might be able to be.