For a Sacramento teenager, medical coverage of early treatment for psychosis proved lifesaving

By Samantha Young

SACRAMENTO — Summer Oriyavong first heard the bells and knocking noises in her head when she was in middle school. Whispering voices and dark visions, those that made her feel superior and special, soon followed.

It wasn’t until one day when Oriyavong ran out of her classroom in terror that her teachers and parents realized she needed help they couldn’t provide. The shadow people told Oriyavong that his classmates were going to harm him.

“I felt like the hallucinations were my friends, so I didn’t feel alone,” said Summer, now a freshman at an independent high school in Sacramento County. “It was just scary.”

The 16-year-old girl from Rio Linda, a suburb of Sacramento, was the lucky recipient of what her mother described as life-saving mental health care from a early psychosis program at the University of California-Davis, largely covered by Medi-Cal, California’s version of Medicaid. The UC Davis program offers intensive treatment that doctors hope will allow people with serious mental illness to live normal lives and save taxpayers money that might otherwise be spent on more emergency interventions. expensive.

Oriyavong is among as many as 2 million people in the United States of schizophrenia, a brain disorder whose symptoms may include delusions, hallucinations, disorganized speech and thought disorders.

More than half of Americans have schizophrenia or another mental illness did not receive the care they needed in 2021, according to the National Alliance on Mental Illness, an advocacy group. Commercial insurance plans aren’t required to cover the kind of specialty care recommended by the National Institute of Mental Health for serious mental illnesses, and most don’t.

Federal law requires states to provide mental health treatment to Medicaid enrollees under age 21, and a few places, such as new York And Texas, have statewide programs. In California, the level of care may depend on where you live: counties are responsible for providing specialized care to people with severe mental illness who are enrolled in Medi-Cal. And counties allocate funding in different ways. (Medic-Cal insurers, which serve approximately 15 million low-income or disabled, covers treatment for mild to moderate mental health conditions such as anxiety.)

“This care is not available to all Californians,” said Tara Niendam, executive director of UC Davis’ early psychosis programs and leader of a state effort to set up programs elsewhere. Sacramento County.

The UC Davis program costs more than Medi-Cal pays, and Sacramento County uses state and federal grants to cover the difference. As of last year, 41% of California counties now have early psychosis programs or were expanding them, Niendam said.

During his two-year stint with the UC Davis EDAPT clinic, Oriyavong underwent coordinated specialist care to early psychosis, treated by a team of psychiatrists, therapists, education specialists, and peer and family advocates. She was often at the clinic two to three times a week — more if she was having a bad time, like cutting herself or stealing Benadryl to overdose.

Oriyavong had nothing to pay, including two stays in psychiatric hospitals and another in a local intensive care unit. His mother, Sheri Oriyavong, never had to negotiate coverage. If Medi-Cal and Sacramento County didn’t pay the bills, “it would just be too much,” she said.

In most cases, schizophrenia first appears in men in their late teens or early twenties. In women, it often strikes in their twenties or early thirties. Research shows that early interventions, including medications and therapy, make a big difference in people’s ability to manage their symptoms.

Extending such treatment to the roughly 27,000 Californians expected to develop psychosis each year remains a mammoth undertaking, with only one-tenth the number of slots available statewide, Niendam told lawmakers at a hearing. on the Assembly’s budget in mid-April. How much it would cost is unclear, and the state Mental Health Services Oversight and Accountability Commission, MHSOAC, is seeking the green light from the legislature to map the costs and benefits.

Advocates believe taxpayers will save money in the long run by helping patients keep jobs and avoid becoming homeless.

“It would be an upfront investment, but it would be a cost saving down the road,” said Kerry Ahearn, CEO of Aldéa Child and Family Services, a nonprofit organization that provides specialized mental health services in Napa, Solano, and Sonoma counties. “People thought people with psychosis were one in a million and it’s so bad you can’t treat it. That’s not true.”

A small, publicly funded pilot project at Kaiser Permanente aims to demonstrate that coverage for serious mental health conditions can also save health plans money.

“The assumption is that by helping the client manage their psychosis, they will be able to better manage their diabetes, for example,” said Toby Ewing, executive director of MHSOAC. “And so total health care costs will actually go down.”

Now that Oriyavong has learned to recognize her triggers and symptoms, she is well on her way to graduating from high school a semester early. She is thinking about finding a job and going to community college.

“I used to think that people with schizophrenia wouldn’t live normal lives, even people would be scared of them,” Oriyavong said. “But actually they can live like normal people.”

This article is part of “Faces of Medi-Cal,” a California Healthline series exploring the impact of the state’s safety net health program on enrollees.

KFF Health News is a national newsroom that produces in-depth journalism on health issues and is one of the main operating programs of KFF – an independent source of health policy research, polling and journalism. Learn more about KFF.

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