For years, she refused help, insisting to all who offered, “I’m not sick,” until police arrested her for petty theft and public drunkenness. A judge gave her an ultimatum: jail or treatment. She chose treatment.

“I’m so thankful that they did that,” said Sweeney, now 52. “I needed that. I think there’s others out there that need it, too.”

If she hadn’t been compelled to get care, Sweeney said, she wouldn’t be alive today, back at work and reunited with her husband. It’s why she supports California’s new civil CARE Courts that will launch this fall in eight counties, including San Francisco, Los Angeles, and Orange, followed by the rest of the state in 2024.

Under the new system, family members and first responders can ask county judges to order people with psychotic illness into treatment, even if they are not unhoused or haven’t committed a crime. A judge will then determine if a person meets criteria for the program and may oversee a care agreement or compel a treatment plan. That treatment plan could even include involuntary commitment.

The bill creating the program sailed through the state legislature with near-unanimous support last year amid growing frustration from voters over the state’s increasing number of homeless people, even as it drew vehement opposition from disability rights groups, who argued CARE Courts’ hallmark — compelling people who have done nothing wrong into mental health care — is a violation of civil rights.

That tension — between those who advocate for treatment being voluntary and those who say the status quo allows people to die in the streets “with their rights on” — is playing out all over the state of California. In Orange County, officials are threading a delicate needle: how to convince people to accept care without coercion, particularly when their illness causes them to believe they are not ill.

“We don’t want to punish people,” said Maria Hernandez, the presiding judge for Orange County Superior Court. “We want them to maintain their dignity.”

Orange County is expecting between 900 and 1,500 residents will be eligible for CARE Court in any given year, according to the county public defender’s office. Local lawyers, judges, and health officials have all aligned in designing their program with a distinct patient focus, endeavoring to make the process as benign and nonthreatening as possible.

Hernandez said that means modeling the new civil court after the county’s other collaborative courts, where judges often lose the black robe and come down off the bench to work with people, eye to eye.

One prototype, she said, is her Young Adult Court, where, on a day in June, the mood was downright jovial. Defendants and their family members were chatting and laughing, munching on snacks laid out on a table in the back as three young men “graduated” from the diversion program.

“Judge Hernandez is so awesome,” said Abraham, 25, a graduate of the program, who asked to be identified only by his first name because he was charged with a felony that has since been expunged from his record. “I don’t even look at her as the judge. She’s just like a mom figure. She’s only trying to push you to be the better you.”

A minute later, Hernandez walked through the aisle of the courtroom and gave Abraham a hug.

Even if CARE Court is overseen by a judge like Hernandez, patient advocates object to the idea. Orlando Vera, who lives with bipolar disorder, said helping a vulnerable person heal from mental illness shouldn’t involve dragging them into a courtroom.

“It’s not a place you resolve your emotions. It is a very business-oriented environment. So I do feel that this is not the place for it,” Vera said, adding, “Can we stop it? I would say we can’t.”

After advocates failed to persuade the state Supreme Court to block the program on constitutional grounds, some started referring to gearing up for the rollout of CARE Court as “disaster preparedness,” equating it with a devastating earthquake or wildfire.

Peer Voices of Orange County, a group Vera co-founded and runs, plans to install patient advocates at the courthouse to attend all CARE Court hearings.

“Our focus is how do we support those that are going through the system,” he said. “We need to be their voice.”

Orange County behavioral health director Veronica Kelley is sympathetic to advocates’ concerns. She said CARE Court is not the program she would have created to improve the state’s mental health system. But she serves at the will of the governor and other elected officials who control her budget.

“So we end up building the Winchester Mystery House,” she said, referring to the 100-year-old mansion in San Jose known for its mazelike layout. “It is a structure that was OK, but then it just started adding hallways to nowhere and basements that are on top of the building. That’s what our system looks like.”

Kelley is trying to shape the new court process into something its critics can accept. This is why she wanted Orange County to go first: “so we can help craft it into something that’s not another colossal waste of time and funds, and that we don’t destroy the people we’re trying to serve at the same time,” she told a roomful of patient advocates during a meeting of the state Patients Rights Committee, held in Santa Ana.

This means social workers from her behavioral health department or the public defender’s office might visit people 20, 30, or 40 times to build trust, listen, and set goals.

Under the CARE legislation, county courts are allowed to fine public behavioral health agencies $1,000 a day if they can’t find a patient and enroll them in treatment by certain deadlines.

Kelley said her county’s judges have agreed to give her staff the time and extensions they need to do their jobs well. She also vowed that no one who declined services in her county would be institutionalized involuntarily, even though the new legislation allows it.

“If someone agrees to do something of their own accord, it is far more probable that there will be long-term success and long-term commitment to the services being provided,” she said.

Kelley pointed to the county’s success with another civil court process, established by Laura’s Law in 2002, in which, for every person involved in court-ordered outpatient care, another 20 accepted treatment willingly.

She said the county has the same goal for CARE Court, with the focus on finding a treatment plan people accept voluntarily, before a judge has to order it.

This article is from a partnership that includes KQED, NPR, and KFF Health News.

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Then, a nurse at her high school’s health clinic in Oakland, California, explained the legal landscape of her new four-year home in Texas — where abortion is now fully banned.

Vital watched TikTok videos of protesters harassing women outside clinics in other states. She realized her newfound freedoms would come at the expense of another. That’s when she added one more task to her off-to-college checklist: get a long-acting, reliable form of birth control before leaving California.

“I don’t want to go out there and not know anything, not know where to go, because I’m in a new state. So I’m trying to be as prepared as I can before I leave,” she said.

The change is a huge culture shock for Vital and some of her classmates, who for the past four years at Oakland Technical High School have had access to their own health clinic on campus.

The “TechniClinic” is a bright-purple building across from the football field and bleachers. The school’s bulldog mascot is painted near the door. On-site, students can get free, confidential birth control consults and screenings for sexually transmitted infections and be back at their desks for fourth-period math.

This summer, nurses at the Oakland clinic have formalized the “senior send-off” appointment, during which they counsel students about their legal rights and medical options before they leave for college.

After Roe v. Wade was overturned last year, clinic staffers realized students of color could be disproportionately affected by changes in state abortion laws. Many of them, like Vital, were choosing to go to historically Black colleges and universities in Southern states, where bans and limits on the procedure are more common.

“Many students here are just totally floored when I tell them that these laws are different in the states that they’re going to,” said Arin Kramer, a family nurse practitioner at the TechniClinic. Like many adults, “they can’t believe that they can’t get an abortion in this country.”

Kramer has been writing prescriptions for a year’s supply of contraceptive pills or patches, which students can pick up all at once.

Under California law, students can get contraception for free, without having to tell their parents or use a parent’s insurance plan. Students can pick up the prescription at the school clinic, or Kramer can call it in to a pharmacy near the student’s home.

During her own “senior send-off” appointment, Vital told nurse Kramer she was in the market for something even more reliable than pills.

“Because I’m very forgetful. Even if I set an alarm or write it down, it will still slip my mind,” Vital said.

She wanted a long-term contraceptive, like an IUD or a hormonal implant that would last for years and require no upkeep.

The American College of Obstetricians and Gynecologists and the American Academy of Pediatrics have made these options their top recommendation for adolescents after research from both groups showed they were safe and highly effective at preventing teen pregnancy.

So at Oakland Tech and other school-based health clinics run by nonprofit La Clínica de La Raza, Kramer has trained other nurse practitioners how to insert these devices — so students can get them the same day they ask for them.

After reviewing the options, Vital decided she wanted a contraceptive implant. During their discussion, Kramer used clear, direct terms, even dropping in phrases students use themselves.

“Who are you talking to these days?” Kramer asked Vital, which is teen-speak for: Who are you having sex with?

“Same person,” Vital replied.

“You guys have been off and on, off and on,” Kramer said. “How do you feel going forward?”

“Well, now they’re on because he’s going to Texas, too,” Vital revealed with a smile. “He’s going with me.”

The clinic staff started preparing the exam room, so Vital could get the implant right away. Kramer turned on some calming music on her phone, washed her hands and had Vital lie down and raise her left arm over her head. Physician assistant Andrea Marquez came in to hold Vital’s other hand and offer words of encouragement.

“I’m going to count to three and then you’ll feel a little pinch,” Kramer said, before giving Vital a shot of numbing medication in her tricep area. Then she coached her through a series of deep breaths before inserting the tiny rod under the skin of her upper arm.

The whole procedure took less than 10 minutes, and Vital walked out with a birth control method that will last her up to five years. Now, she said, she can focus on her education and fully experience the new freedoms of college.

“I’m really excited for the growing up part of it,” she said.

Meanwhile, Kramer headed back to her office. She had a list of other patients to check up on, many headed to states that ban abortion. As they pack their books and bed linens for their new dorm rooms, she’s reminding them to also pack a year’s supply of contraception, too.

University-based health centers also are reconsidering their clinical protocols in the wake of the Dobbs v. Jackson Women’s Health Organization Supreme Court ruling that overturned Roe.

In 2020, only 35% of colleges offered on-site IUD insertion and 43% offered contraceptive implant insertion, according to a survey by the American College Health Association.

That group now recommends college clinics do routine pregnancy screenings to identify pregnancies as early as possible, to give students more time to consider their options, and to have legal counsel on call to advise clinicians on allowable practices.

Attorneys might even help advise university health centers about how to have conversations with patients, especially in states like Texas, where local law forbids clinicians from “aiding and abetting” patients who seek abortion care. These new threats — of prosecution or pulled funding — have complicated clinicians’ communication with their collegiate patients.

“So I’m going to be vague with my wording, purposefully,” said Yolanda Nicholson, director of clinical education at the North Carolina Agricultural and Technical State University health center, and chair for the coalition of Historically Black Colleges and Universities of the American College Health Association.

Nicholson thinks the concept of the senior send-off appointment in the student’s home state is a great one, given that college health centers in Texas and throughout the South have had to adjust their educational approach with students to be more general and “maybe not as specific or targeted as we would have previously done,” to stay aligned with local laws.

Out-of-state students are often shocked to discover they don’t have access to the same services as they do at home, she said.

This article is from a partnership that includes KQED, NPR, and KFF Health News.

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Mental illness can be part of the story of how a person ends up homeless — or part of the price of survival on the streets, where sleep and safety are scarce. Homeless people in Multnomah County, which includes Portland, die about 30 years earlier than the average American. These grim realities have ratcheted up the pressure on politicians to do something.

High housing costs and financial adversity are among the root causes of the burgeoning population on the streets.

About 1 in 3 people who are homeless in Portland report having a mental illness or a substance use disorder, and the combination of homelessness and substance use or untreated mental illness has led to very public tragedies.

People with schizophrenia, for example, have died of hypothermia on the city’s streets. One resident gave birth in a snowstorm to a stillborn infant. Methamphetamine, cheaper and more potent than it used to be, is creating a heightened risk of overdose and psychosis.

In Oregon, some politicians, including Portland Mayor Ted Wheeler, have proposed changing the civil commitment law so doctors have more leeway in compelling treatment for patients too sick to know they need care. Without such changes, they argue, people with untreated addictions or mental illnesses are stuck cycling between the streets, county jails, and state psychiatric hospitals.

“I think we can do better by people than allowing them to flounder,” said Janelle Bynum, a state legislator who represents suburbs southeast of Portland.

Bynum, a Democrat, signed on to a pair of bills, introduced by Republicans this year, that would expand the criteria for involuntary commitment in Oregon.

“My intention was to signal how cruel I think our current system is,” she said.

Half of the country’s unsheltered people live in California, and though only about a quarter to a third of homeless people are estimated to have a serious mental illness, they are the ones other residents are likely to encounter in California’s cities. Mayors from San Francisco, San Jose, and San Diego have all expressed frustration that the threshold for psychiatric intervention is so high.

‘Why Aren’t You Doing Something?’

“When I’m often asked, ‘Mayor, why aren’t you doing something about this person who is screaming at the top of their lungs on the street corner?’ and I said, ‘Well, they’re not a threat to themselves or to others,’ that rings hollow,” said Todd Gloria, mayor of San Diego.

Now, state lawmakers in Sacramento, backed by mayors, have introduced laws and bills that would help bring more people into treatment, even against their will.

Last year, legislators approved a new approach to mental health care — called CARE Court — that allows judges to issue treatment plans for people with certain diagnoses. That program begins on a pilot basis this fall in seven counties, including San Diego and San Francisco counties, with the rest of the state expected to join next year.

This year, a bill moving through the legislature would expand who qualifies for a conservatorship or involuntary psychiatric hold.

The bill is gathering support and sponsors are optimistic that Democratic Gov. Gavin Newsom will sign it if it passes. But it’s been controversial: Opponents fear a return to bygone policies of locking people up just for being sick.

Half a century ago, California policymakers shuttered state psychiatric institutions, denouncing them as inhumane. Involuntary commitment was de-emphasized, and state laws ensured that it was used only as a last resort. The thinking was that the patient should have autonomy and participate in their care.

But politicians across California are now reconsidering involuntary commitments. They argue that not helping people who are seriously ill and living in squalor on the streets is inhumane. Psychiatrists who support the bill say it would constitute a modest update to a 56-year-old law.

The shift is dividing liberals over the very meaning of compassion and which rights should take precedence: civil rights like freedom of movement and medical consent, or the right to appropriate medical care in a crisis?

“The status quo has forced too many of our loved ones to die with their rights on,” said Teresa Pasquini, an activist with the National Alliance on Mental Illness. Her son has schizophrenia and has spent the past 20 years being “failed, jailed, treated, and streeted” by what she called a broken public health system.

“We are doctors who have to watch these people die,” said psychiatrist Emily Wood, chair of the government affairs committee of the California State Association of Psychiatrists, a sponsor of the conservatorship bill, SB 43. “We have to talk to their families who know that they need that care, and we have to say we don’t have any legal basis to bring them into the hospital right now.”

Under current California law, a person can be held in the hospital involuntarily if they are a danger to themselves or others or if they are unable to seek food, clothing, or shelter as a result of mental illness or alcoholism. Doctors want to add other substance use disorders to the criteria, as well as an inability to look out for one’s own safety and medical care. (The state law defines what is known as “mental health conservatorship,” which is separate from the probate conservatorship that Britney Spears was under.)

Wood, who practices in Los Angeles, gave two examples of people she and her colleagues have tried, but struggled, to care for under the current rules. One is a man who doesn’t take his diabetes medication because he’s not taking his schizophrenia medication and doesn’t understand the consequences of not managing either condition.

Wood explained that even if he repeatedly ends up in the emergency room with dangerously high blood sugar, no one can compel him to take either medication under current law, because poorly managing one’s health is not a trigger for conservatorship.

Another man Wood described has a developmental disability that went untreated in childhood. He developed an addiction to methamphetamine in his 20s. Wood said the man is now regularly found sleeping in a park and acting inappropriately in public. His family members have begged doctors to treat him, but they can’t, because substance use disorder is not a trigger for conservatorship.

To Wood, treating these people, even when they’re unable to consent, is the compassionate, moral thing to do.

“It’s essential that we respect all the rights of our patients, including the right to receive care from us,” she said.

But other advocates, including some of those working for Californians with mental illnesses, see the issue very differently.

Lawyers from the nonprofit Disability Rights California said the proposed expansion of conservatorship and the ongoing rollout of CARE Courts are misguided efforts, focused on depriving people of their liberty and privacy.

Instead, they said, the state should invest in better voluntary mental health services, which help maintain people’s dignity and civil rights. The group filed a petition in January to try to block the implementation of CARE Courts.

These advocates are particularly concerned that people of color, specifically Black residents, who are overrepresented in the homeless population and overdiagnosed with schizophrenia, will now be disproportionately targeted by more forceful measures.

“When people are told that they have to go to court to get what they should be getting voluntarily in the community, and then they get a care plan that subjugates them to services that still do not meet their cultural needs, that is not compassion,” said Keris Myrick, an advocate who has schizophrenia and has experienced homelessness.

More Housing: Another Badly Needed Prescription

Under current state law in Oregon, a person can be held for involuntary treatment if they are a danger to themselves or others or are at risk of serious physical harm because they cannot provide for their basic personal needs due to a mental illness.

Oregon, like California, does not include substance use disorders as grounds for commitment.

But its law is slightly broader than California’s, at least in one respect: Legislators amended it in 2015 to give doctors more leeway to step in if a person’s psychosis or other chronic mental illness is putting them at risk of a medical crisis.

Terry Schroeder, a civil commitment coordinator with the Oregon Health Authority, said that, before the change, a person would have to be nearly comatose or within a few days of death to meet the criteria for doctors to forcibly treat them for their own welfare.

The law now allows care providers to intervene earlier in an ongoing medical crisis.

In Oregon and California, the lack of adequate treatment options is frequently invoked in the ongoing debates over forced commitment and conservatorship.

“Expanding conservatorships doesn’t solve for those structural issues around the lack of housing and the lack of funding for treatment services,” said Michelle Doty Cabrera, executive director of the County Behavioral Health Directors Association of California.

Cabrera’s group also questions the premise that forced treatment works, and there is indeed little evidence that compulsory treatment for substance use disorder is effective, and some evidence that it could even be harmful.

Critics of involuntary commitment have questioned the California Legislature’s objectives. If the ultimate goal of forced treatment is to reduce homelessness — and ease the moral failing of ill people sleeping on the street or using drugs in the open — then lawmakers are writing the wrong prescription, they said.

“The problem of homelessness is that people don’t have housing,” said primary care physician Margot Kushel, director of the University of California-San Francisco’s Benioff Homelessness and Housing Initiative.

“If you had all the treatment in the world and you didn’t have the housing, we would still have this problem.”

Supporters of involuntary commitments say both are needed. Many of the California lawmakers backing expanded conservatorship and CARE Courts are also backing efforts to increase the housing supply, including a $3 billion bond measure for the construction of small, neighborhood-oriented residences for people with mental illness.

Nationwide, rents have risen more quickly than people’s incomes in the past 20 years, particularly impacting people who rely on a fixed income, such as monthly disability payments.

This article is part of a partnership that includes KQED, OPB, and KFF Health News.

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Estos comités de revisión de la mortalidad materna buscan pistas sobre lo que ha contribuido a estas muertes —recetas que nunca se recogieron, faltar a citas médicas postnatales, señales de alerta que los médicos pasaron por alto—, para averiguar cuántas podrían haberse evitado y cómo.

Los comités trabajan en 36 estados, y en la última y mayor recopilación de datos de este tipo, publicada en septiembre por los Centros para el Control y Prevención de Enfermedades (CDC), un sorprendente 84% de las muertes relacionadas con el embarazo se consideraron prevenibles.

Lo que resulta aún más alarmante para enfermeras-detectives como Sheffield-Abdullah es que el 53% de las muertes se produjeron mucho después de que las mujeres fueran dadas de alta del hospital, entre siete días y un año después del parto.

“Estamos muy centrados en el bebé”, afirma. “Una vez que el bebé está aquí, es casi como si la madre fuera descartada… Y en lo que realmente tenemos que pensar es en ese cuarto trimestre, ese tiempo después del nacimiento del bebé”.

Las condiciones de salud mental fueron la principal causa subyacente de muertes maternas entre 2017 y 2019. Las blancas no hispanas y las hispanas fueron las más propensas a morir por suicidio o sobredosis de drogas, mientras que los problemas cardíacos fueron la principal causa de muerte para las mujeres negras no hispanas.

Ambas circunstancias ocurren desproporcionadamente más tarde en el período posparto, según el informe de los CDC.

Los datos revelan múltiples deficiencias en el sistema de atención a las nuevas madres, desde los obstetras que no están adiestrados (o bien pagados) para buscar signos de problemas mentales o de adicción, hasta las pólizas que despojan a las mujeres de la cobertura médica poco después de dar a luz.

El principal problema es que el típico control postnatal de seis semanas es demasiado tarde, según Sheffield-Abdullah. En los datos de Carolina del Norte, las nuevas madres que murieron más tarde no acudieron a esta cita porque tenían que volver al trabajo o tenían otros niños pequeños, agregó.

“Tenemos que estar realmente en contacto mientras están en el hospital”, dijo Sheffield-Abdullah, y luego asegurarnos de que las pacientes reciban la atención de seguimiento adecuada “una o dos semanas después del parto”.

Otra de las recomendaciones de los CDC es más pruebas de detección de depresión y ansiedad posparto, durante todo el año posterior al parto, así como una mejor coordinación de la atención entre los servicios médicos y sociales, según David Goodman, que dirige el equipo de prevención de mortalidad materna de la División de Salud Reproductiva de los CDC, que publicó el informe.

Una crisis frecuente es que la adicción de uno de los padres se agrava tanto que los servicios de protección infantil se llevan al bebé, lo que precipita una sobredosis accidental o intencionada de la madre. Tener acceso al tratamiento y asegurarse de que las visitas a los niños se produzcan con regularidad podría ser la clave para prevenir estas muertes, apuntó Goodman.

El cambio político más importante ha sido la ampliación de la cobertura sanitaria gratuita a través de Medicaid, indicó. Hasta hace poco, la cobertura de Medicaid relacionada con el embarazo solía expirar dos meses después del parto, lo que obligaba a las mujeres a dejar de tomar medicamentos o de acudir a un terapeuta o a un médico porque no podían pagar el costo sin seguro médico.

Ahora, 36 estados han ampliado o tienen previsto ampliar la cobertura de Medicaid hasta un año completo después del parto, en parte como respuesta a los primeros trabajos de los comités de revisión de la mortalidad materna.

“Si esto no es una llamada a la acción, no sé qué es”, señaló Adrienne Griffen, directora ejecutiva de la Maternal Mental Health Leadership Alliance, una organización sin fines de lucro centrada en la política nacional. “Hace tiempo que sabemos que los problemas de salud mental son la complicación más común del embarazo y el parto. Solo que no hemos tenido la voluntad de hacer algo al respecto”.

El último estudio de los CDC de septiembre analizó 1,018 muertes en 36 estados, casi el doble de los 14 estados que participaron en el informe anterior. Los CDC están dando aún más fondos para las revisiones de la mortalidad materna, dijo Goodman, con la esperanza de captar datos más completos de más estados en el futuro.

El aumento de la concientización y la atención sobre la mortalidad materna les ha dado esperanza a activistas y médicos, especialmente por los esfuerzos para corregir las disparidades raciales: las mujeres negras tienen tres veces más probabilidades de morir por complicaciones relacionadas con el embarazo que las blancas.

Pero muchos de estos mismos partidarios de una mejor atención materna dicen estar consternados por la reciente decisión del Tribunal Supremo de Estados Unidos de erradicar el derecho federal al aborto; las restricciones en torno a la atención de la salud reproductiva, dicen, erosionarán los avances.

Desde que estados como Texas empezaron a prohibir los abortos en etapas tempranas del embarazo y a hacer menos excepciones para aquellos casos en los que la salud de la embarazada está en peligro, a algunas mujeres les resulta más difícil recibir atención de urgencia por un aborto espontáneo.

Los estados también están prohibiendo los abortos —incluso en casos de violación o incesto— en chicas jóvenes, que afrontan un riesgo mucho mayor de complicaciones o muerte por llevar un embarazo a término.

“Cada vez más el mensaje es que ‘no eres dueña de tu cuerpo'”, dijo Jameta Nicole Barlow, profesora adjunta de redacción, política y gestión sanitaria en la Universidad George Washington.

Según Barlow, esto no hará más que agravar los problemas de salud mental que experimentan las mujeres en torno al embarazo, especialmente las mujeres negras, que también se enfrentan a la larga historia intergeneracional de la esclavitud y el embarazo forzado. Sospecha que las cifras de mortalidad materna empeorarán antes de mejorar, debido a la interrelación entre la política y la psicología.

“Hasta que no abordemos lo que está ocurriendo políticamente”, dijo, “no vamos a poder ayudar a lo que está ocurriendo psicológicamente”.

Esta historia es parte de una alianza que incluye a KQED, NPR, y KHN.

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

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These maternal mortality review committees look for clues about what contributed to the deaths — unfilled prescriptions, missed postnatal appointments, signs of trouble that doctors overlooked — to figure out how many of them could have been prevented.

The committees are at work in 36 states, and in the latest and largest compilation of such data, released in September by the Centers for Disease Control and Prevention, a staggering 84% of pregnancy-related deaths were deemed preventable.

Even more striking to nurse-detectives like Sheffield-Abdullah is that 53% of the deaths occurred well after women left the hospital, between seven days and a year after delivery.

“We are so baby-focused,” she said. “Once the baby is here, it’s almost like the mother is discarded. Like a Reese’s Peanut Butter Cup. The mom is the wrapper, and the baby is the candy. Once you remove the wrapper, you just discard the wrapper. And what we really need to be thinking about is that fourth trimester, that time after the baby is born.”

Mental health conditions were the leading underlying cause of maternal deaths between 2017 and 2019, with white and Hispanic women most likely to die from suicide or drug overdose, while cardiac problems were the leading cause of death for non-Hispanic Black women, according to the CDC report.

The data highlights multiple weaknesses in the system of care for new mothers, from obstetricians who are not trained (or paid) to look for signs of mental trouble or addiction, to policies that strip women of health insurance coverage shortly after they give birth.

The No. 1 problem, as Sheffield-Abdullah sees it, is that the typical six-week postnatal checkup is way too late. In the North Carolina data, new moms who later died often missed this appointment, she said, usually because they had to go back to work or they had other young children.

“We really need to stay connected while they’re in the hospital,” Sheffield-Abdullah said, then make sure patients are referred for the appropriate follow-up care “within one to two weeks after delivery.”

Increased screening for postpartum depression and anxiety, starting at the first prenatal visit and continuing throughout the year after birth, is another CDC recommendation, as is better coordination of care between medical and social services, said David Goodman, who leads the maternal health team at the CDC’s Division of Reproductive Health, which issued the report.

A common crisis point in the months after childbirth is when a parent’s substance use problem gets so bad that child protective services takes the baby away, precipitating a mother’s accidental or intentional overdose. Having access to treatment and making sure child visitations happen regularly could be key to preventing such deaths, Goodman said.

The most important policy change underscored by the data, he said, has been the expansion of free health coverage through Medicaid. Until recently, pregnancy-related Medicaid coverage typically expired two months after delivery, forcing mothers to stop taking medications or seeing a therapist or doctor because they couldn’t afford the cost without health insurance.

Now, 36 states have either extended or plan to extend Medicaid coverage to a full year postpartum, partly in response to the early work of maternal mortality review committees. For years, the data showed about a third of pregnancy-related deaths occurred one year after delivery, but in this report, they jumped to more than half, Goodman said, putting more urgency on the importance of longer-term Medicaid coverage.

“If this is not a call to action, I don’t know what is,” said Adrienne Griffen, executive director of the Maternal Mental Health Leadership Alliance, a nonprofit focused on national policy. “We’ve long known that mental health issues are the most common complication of pregnancy and childbirth. We just haven’t had the will to do anything about it.”

The latest CDC study from September analyzed 1,018 deaths in 36 states, significantly more than in the previous report. The CDC is providing additional funding for maternal mortality reviews, Goodman said, with the hope of capturing more complete data from more states in the future.

Advocates and doctors have been heartened by the increased awareness and attention on maternal mortality, especially efforts to correct racial disparities: Black women are three times as likely to die from pregnancy-related complications as white women.

But many of these same advocates for better maternal care say they are dismayed by the recent U.S. Supreme Court decision eradicating the federal right to abortion; restrictions around reproductive health care, they say, will erode the gains.

Since states like Texas began banning abortions earlier in pregnancy and making fewer exceptions for cases in which the pregnant person’s health is endangered, some women are finding it harder to get emergency care for a miscarriage.

States are also prohibiting abortions — even in cases of rape or incest — for young girls, who face much higher risks of complications or death from carrying a pregnancy to term.

“More and more women and other birthing individuals are receiving messages that ‘You don’t have ownership of your body,'” said Jameta Nicole Barlow, an assistant professor of writing, health policy, and management at George Washington University. “Whether it’s through policy, whether it’s through your doctor who has to adhere to policy, whether it’s through your daily work experience, there’s this acknowledgment that ‘I don’t own my body.'”

This will only exacerbate the mental health struggles women experience around pregnancy, Barlow said, especially Black women who are also coping with a long, intergenerational history of slavery and forced pregnancy. She suspects the maternal mortality numbers will get worse before they get better, because of the way politics, policy, and psychology are intertwined.

“Until we address what’s happening politically,” she said, “we’re not going to help what’s happening psychologically.”

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During the legislative debate over the amendment, dubbed Proposition 1 on the November ballot, there were several awkward moments after a question from Republicans stumped Democrats — most notably when Assembly member Kevin Kiley (R-Rocklin) posed it point-blank before the final vote in June. “California law generally bars the performance of an abortion past the point of fetal viability,” he said. “Would this constitutional amendment change that?”

The floor went quiet. For a full 30 seconds, no one said anything. Assembly Speaker Anthony Rendon whispered with Democratic colleagues, asked to have the question repeated, and then promised to answer later. He never did.

Viability has long been a controversial concept, plaguing ethicists on both sides of the abortion debate since it was embedded in the Roe v. Wade decision in 1973. The Supreme Court justices wrote that a woman’s right to privacy was protected only up to viability — the point when a fetus is capable of “meaningful life outside the mother’s womb.” The court said that occurs between 24 and 28 weeks after conception.

Since then, many doctors have bemoaned the legal and political bastardization of the medical concept, arguing that viability is much more complex than gestational age alone. But the public has clung to it, and both opponents and supporters of abortion rights have looked favorably on restricting access to the procedure later in pregnancy.

Current California law incorporates the viability limit from Roe, allowing abortion for any reason through most of the second trimester and after that only if the patient’s or fetus’s health is in danger.

But the constitutional amendment outlined in Proposition 1 doesn’t contain the word “viability.” Even among legal scholars, there is no consensus about whether that means the viability standard in place now will remain if Proposition 1 is approved or if time limits on abortion will be eradicated in California.

“It at least opens the door,” said Mary Ziegler, a law professor at the University of California-Davis, with courts likely making the final interpretation of Proposition 1 after the vote, if it’s approved.

The V-Word Debate Revived

When Assembly member James Gallagher (R-Chico) spoke during the final floor debate in June, his voice wavered with emotion. He could not support the constitutional amendment, he said, “because of what’s missing from it.”

He choked up at one point talking about his twin boys, who were born 2½ months premature and almost needed heart surgery in utero. “They were alive, and they were people,” he repeated throughout his speech, pointing at the lectern for emphasis each time, as he recounted his wife’s pregnancy at 18 weeks, 23 weeks, and 30 weeks.

With no time limits on abortion, Gallagher said, the amendment got the balance wrong between the rights of the mother and the fetus.

“We can do better,” he said.

Proponents of Proposition 1 have said the intention was only to preserve the status quo. But in various committee hearings, supporters at times seemed confused by the language of their own bill and scrambled to answer definitively when asked whether the amendment would preserve the viability limit or discard it.

But physicians involved in drafting the amendment, like Dr. Pratima Gupta, said no mistake was made: The word viability was left out on purpose.

“Every pregnancy is individual, and it’s a continuum,” said Gupta, an OB-GYN in San Diego. People come into pregnancy with a range of preexisting health conditions, she said, including diabetes, anemia, high blood pressure, and obesity. They may not have much money or access to good medical care, with the latest technology. All these very nuanced factors determine whether a fetus is viable, she said, not some arbitrary number.

“If I see a patient who has broken their bag of water at 23 weeks of pregnancy, that doesn’t mean that it’s viable or not viable,” she said, explaining that the fetus may survive premature delivery at this stage in some cases but not in others.

Doctors who consulted on the amendment were following the lead of the American College of Obstetricians and Gynecologists, the leading advisory group for OB-GYNs, which removed the term viability from its guidance on abortion in May. The term has become so politicized that it barely has any medical meaning anymore, the group said, and deciding whether and when to have an abortion should be left to the patient and doctor.

Strangely, the demise of Roe v. Wade has freed doctors from the vagaries of the viability framework as it was outlined in that ruling. Physicians seem to be saying that if the Supreme Court could put an end to 50 years of constitutional protections for abortion, the court could take all the flaws of the decision with it.

“In a world where there is no Roe, I think you’re seeing California legislators trying to write into law a kind of blank slate, a better idea of what reproductive autonomy could be that isn’t just Roe Part 2,” Ziegler said.

Why Women Get Abortions Later in Pregnancy

In recent years, at least three other states — Colorado, New Jersey, and Vermont — and Washington, D.C., have removed gestational age limits from their abortion laws.

Abortion opponents argue that if California follows suit, it will be a free-for-all, with women lining up for abortions when they’re eight months pregnant.

“We already currently have abortion up to 24 weeks. Why do we need to push it beyond that?” said Jonathan Keller, president and CEO of the California Family Council, a religious nonprofit. “Aren’t we able to say that that is a step too far, even for California?”

Research indicates such scenarios are highly unlikely. Abortions at or after 21 weeks represent only 1.2% of all abortions, according to data from the Centers for Disease Control and Prevention. And studies show the reasons women seek abortions at that point vary, from medical complications that threaten the life of the patient or fetus to, increasingly, legal and logistical barriers.

“It may be that they’re delayed because there are lots of restrictions they have to comply with; it may be because they need to travel for an abortion,” said Elizabeth Nash, a policy analyst at the Guttmacher Institute, a research organization that supports abortion rights. “It may be that they can’t get time off of work. Or it was a wanted pregnancy and something happened.”

Still, even in California, which positions itself as an abortion sanctuary, voters become more uncomfortable with the procedure the later a pregnancy gets. An August poll found that only 13% of likely voters said they were OK with abortion through the third trimester.

But a different poll found that on the question of securing abortion rights in general, 71% of California voters said they would vote for Proposition 1.

“The politics of viability have changed,” law professor Ziegler said.

With the Supreme Court toppling the federal right to abortion, and more than half the states banning or trying to ban the procedure, she said, “these viability arguments — that had obviously been compelling for decades — don’t land the same way.”

The polls indicate that voters are not inclined to nitpick. Ziegler predicted they’ll accept the ambiguity in Proposition 1 and let the courts sort out the details later.

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And the more serious he got about pot, the more paranoid, even psychotic, he became. He started hearing voices.

“They were going to kill him and there were people coming to eat his brain. Weird, weird stuff,” Kirkaldie said. “I woke up one morning, and no Kory anywhere. Well, it turns out, he’d been running down Villa Lane here totally naked.”

Kory went to live with his grandmother for a couple of years in Napa, California. She thought maybe she could help. Now, she says that was naive.

Kory was diagnosed with schizophrenia. Kirkaldie blames the pot.

“The drug use activated the psychosis, is what I really think,” she said.

Indeed, many scientific studies have linked marijuana use to an increased risk of developing psychiatric disorders, including schizophrenia. The risk is more than four times as great for people who use high-potency marijuana daily than for those who have never used, according to a study published in The Lancet Psychiatry in 2019. One study found eliminating marijuana use in adolescents could reduce global rates of schizophrenia by 10%.

Doctors and lawmakers in California want cannabis producers to warn consumers of this and other health risks on their packaging labels and in advertising, similar to requirements for cigarettes. They also want sellers to distribute health brochures to first-time customers outlining the risks cannabis poses to youths, drivers, and those who are pregnant, especially for pot that has high concentrations of THC, the chemical primarily responsible for marijuana’s mental effects.

“Today’s turbocharged products are turbocharging the harms associated with cannabis,” said Dr. Lynn Silver with the Public Health Institute, a nonprofit sponsoring the proposed labeling legislation, SB 1097, the Cannabis Right to Know Act.

Californians voted to legalize recreational pot in 2016. Three years later, emergency room visits for cannabis-induced psychosis went up 54% across the state, from 682 to 1,053, according to state hospital data. For people who already have a psychotic disorder, cannabis makes things worse — leading to more ER visits, more hospitalizations, and more legal troubles, said Dr. Deepak Cyril D’Souza, a psychiatry professor at Yale University School of Medicine who also serves on the physicians’ advisory board for Connecticut’s medical marijuana program.

But D’Souza faces great difficulty convincing his patients of the dangers, especially as 19 states and the District of Columbia have legalized recreational marijuana.

“My patients with schizophrenia and also adolescents hear very conflicting messages that it’s legal; in fact, there may be medical uses for it,” he said. “If there are medical uses, how can we say there’s anything wrong with it?”

Legalization is not the problem, he said; rather, it’s the commercialization of cannabis — the heavy marketing, which can be geared toward attracting young people to become customers for life, and the increase in THC from 4% on average up to between 20% and 35% in today’s varieties.

Limiting the amount of THC in pot products and putting health warnings on labels could help reduce the health harms associated with cannabis use, D’Souza said, the same way those methods worked for cigarettes.

He credits warning labels, education campaigns, and marketing restrictions for the sharp drop in smoking rates among kids and teens in the past decade.

“We know how to message them,” D’Souza said. “But I don’t think we have the will or the resources, as yet.”

Some states, including Colorado, Oregon, and New York, have dabbled with cannabis warning-label requirements. California’s proposed rules are modeled after comprehensive protocols established in Canada: Rotating health warnings would be set against a bright-yellow background, use black 12-point type, and take up a third of the package front. The bill suggests language for 10 distinct warnings.

Opponents of the proposed labels say the requirements are excessive and expensive, especially since marketing to children is already prohibited in California and people must be 21 to buy.

“This bill is really duplicative and puts unnecessary burdens on the legal cannabis industry, as we already have incredibly restrictive packaging and advertising requirements,” said Lindsay Robinson, executive director of the California Cannabis Industry Association.

The state should focus more on combating the illicit pot market rather than further regulating the legal one, she said. Legal dispensaries are already struggling to keep up with existing rules and taxes — the state’s 1,500 licensed pot retailers generated $1.3 billion in state tax revenue last year. Adding more requirements makes it harder for them to compete with the illicit market, she said, and more likely to go out of business.

“The only real option if they fail out of the legal system is to shutter their businesses altogether or to operate underground. And I don’t think the state of California, with the tax revenue, wants either of those to happen,” Robinson said. “The heart of the issue is that there’s a massive, unregulated market in the state.”

Some people are skeptical that the labels will work. Liz Kirkaldie’s grandson, Kory, is stable now, living with his dad. But she’s not sure a yellow warning would’ve stopped him when he was a teen.

“They’re just not going to pay attention,” she said. “But if it helps even one person? Great.”

Scientists still do not know what causes schizophrenia, but they believe multiple factors are at play, including genetics, family history, trauma, and other influences in a person’s environment, like smoking pot. Some scientists believe having schizophrenia in the first place predisposes people to smoking pot. While it’s difficult to prove a direct causal link between cannabis use and schizophrenia, the associations are strong enough to warrant action, said D’Souza, and, importantly, pot use is one of the few risk factors people can control.

“Not everyone who smoked cigarettes developed lung cancer, and not everyone who has lung cancer smoked cigarettes,” he said. “But I think we would all agree that one of the most preventable causes of lung cancer is cigarette smoking.”

Applying the same health education strategies to cannabis that were used for tobacco, he said, is long overdue.

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At the park near Duboce Triangle in San Francisco, 5 p.m. is canine happy hour. About 40 dogs run around, chasing balls and wrestling, as their owners coo and ’90s hip-hop bumps out of a portable speaker.

One recent afternoon, a Chihuahua mix named Honey lounged on a bench wearing a blue tutu and a string of pearls. Her owner, Diana McAllister, fed her homemade treats from a zip-close bag, then popped one into her own mouth.

After spending two years at home through the pandemic, it’s clear that for a lot of these owners, their dogs are their children.

“I always say, dogs are people, so I love him,” said Yves Dudley, looking on as her 9-month-old collie-schnauzer mix played in the grass.

Across the country, about 23 million families adopted a pet in the first year of the pandemic. Other pet owners, working from home, started paying more attention to their animals’ daily routines, noticing symptoms like vomiting or coughing. The resulting spike in pet health concerns has been straining a corner of the medical world that doesn’t get as much attention as doctors and nurses: veterinarians.

The overwork and staffing shortages of the pandemic have affected veterinarians as much as other doctors and nurses, and dealing with the constant moral dilemmas and emotional output was driving many to burn out even before 2020. The mean salary for vets is about $110,000 per year, according to the Bureau of Labor Statistics, about half that of physicians catering to people.

At the Society for the Prevention of Cruelty to Animals’ veterinary hospital in San Francisco, so many vets and technicians have left that the clinic has had to cut back its hours, said veterinarian Kathy Gervais.

Dog owners say they’ve had to wait months for vet appointments or drive to vets far from home to get care.

“Getting your dog in to see the vet is as competitive as trying to buy Coachella tickets online,” said Laura Vittet, whose golden retriever, Gertrude, is 1½ years old. “You have to wait by the phone, you have to be ready to refresh your browser. It’s a very intense experience.”

Gervais said she works 12-hour days, constantly zigzagging from new puppies to dying cats. And the whole time, she takes care of their humans, too.

“To these people, and especially in these times, this is their love,” she said, thinking especially of the owners who dress and coif and cook for their dogs. “This is their being, this is what they live for. And for vets, it’s very hard for us to draw the line.”

Empathy overload and compassion fatigue affect veterinarians’ mental health. They carry the weight of having to euthanize animals that could be saved but whose owners can’t afford the care. Gervais said her practice euthanizes about five animals every day. Some upset owners become downright abusive when a pet is in distress, berating vets or later bullying them online.

“I dare you to try to talk to a veterinarian who’s been in practice more than five years who doesn’t know somebody who has committed suicide,” said Gervais. “I, unfortunately, can count on more than 10 fingers: classmates, colleagues, people I’ve dated.”

One in 6 veterinarians have considered suicide, according to studies from the Centers for Disease Control and Prevention. While male vets are 1.6 times as likely to die by suicide as the general population, female vets are 2.4 times as likely, and 80% of vets are women.

In the early months of the pandemic, Gervais could see things getting worse. She helped organize the Veterinary Mental Health Initiative, which offers free support groups and one-on-one help to vets across the country.

All the facilitators have doctorate-level training, said founder and director Katie Lawlor, also a psychologist, and they’re all familiar with the issues troubling vets.

“Burnout, compassion fatigue, managing panic attacks, how to communicate with both supervisors, colleagues, and clients when you’re under extreme deadlines or very intense stress,” she said. “And the loss of their own companion animals.”

The initiative helped Dr. Razyeeh Mazaheri work through the anxiety she was feeling every day caring for animals at a clinic outside Chicago last year. The clinic was regularly double- or triple-booked. As a new vet — Mazaheri graduated from veterinary school last spring — juggling so many cases was terrifying.

“I just feel like if I make a mistake, that is a problem. And if I make a mistake and kill something, that is my fault,” she said, tearing up. “I just knew that I was burned out.”

Through the support groups, Mazaheri was able to see that others shared her concerns and she learned coping tools. The initiative, housed under the nonprofit Shanti Project, has groups specifically for emergency vets, vet technicians, recent grads like Mazaheri, and longtime vets like Kathy Gervais who have more than 20 or 30 years of experience.

“I’ve had people look at me sometimes when they’ve seen me really tired, going, ‘Kathy, walk away,’” she said.

“I’m not ready to do it because, bottom line, I love my job. It is a vocation. It is a passion. And it’s hard to walk away from that,” she said. “But if it’s going to kill me on the flip side, I would hope I could just say, ‘OK, that’s it. I’m done.’”

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“It’s when things go really, really fast and they seem overwhelmingly disastrous. That’s when it happens,” said Myrick, who was diagnosed with schizophrenia 25 years ago. “The attacking voices were calling me stupid. … I literally had a meltdown right here in my house. Just lost it.”

She was able to calm herself and quiet the voices, and as the pandemic wore on, she kept them at bay by keeping busy: continuing her work for a foundation, hosting a podcast, and writing a children’s book. She managed, but she worried about other people like her.

“People with schizophrenia were not actually deemed as ‘the priority vulnerable population’ to be served or to be addressed in the same way as people who had other chronic health conditions and who were over a certain age,” said Myrick, who lives in Los Angeles. “So we kind of got left out.”

This omission occurred even as new data published in JAMA Psychiatry showed that people with schizophrenia were nearly three times as likely to die from covid-19 as the general population. Their risk of death from the virus is greater than it is for people with diabetes, heart disease, or any other factor aside from older age.

“People’s initial reaction to this was one of disbelief,” said Katlyn Nemani, a New York University school of medicine neuropsychiatrist and the study’s lead author.

Some researchers initially questioned whether the disparate death rates could be explained by the often poor physical health of people with schizophrenia or their difficulty accessing health care. But Nemani’s study controlled for those factors: All the patients in the study were tested and treated for covid, and they got care from the same doctors in the same health care system.

Then studies started rolling in from countries with universal health care systems — the U.K., Denmark, Israel, South Korea — all with similar findings: a nearly three times higher risk of death for people with schizophrenia. A more recent study from the U.K., published in December 2021, found the risk was nearly five times as great.

“You have to wonder, is there something inherent to the disorder itself that’s contributing to this?” Nemani asked.

The immune dysfunction that causes severe covid in people with schizophrenia could be what drives their psychotic symptoms, Nemani said. This suggests schizophrenia is not just a disorder of the brain, but a disease of the immune system, she said.

Although researchers had already been exploring this theory, the data from the pandemic has shed light on it in a new way, opening doors for discoveries.

“This is a really rare opportunity to study the potential relationship between the immune system and psychiatric illness, by looking at the effects of a single virus at a single point in time,” Nemani said. “It could potentially lead to interventions that improve medical conditions that are associated with the disease, but also our understanding of the illness itself and what we should be doing to treat it.”

In the long term, it could lead to new immunological treatments that might work better than current antipsychotic drugs.

For now, advocates want the data about risk to be shared more widely and taken more seriously. They want people with schizophrenia and their caretakers to know they should take extra precautions. Earlier in the pandemic, they had hoped people with schizophrenia would get vaccine priority.

“It’s been a challenge,” said Brandon Staglin, who has schizophrenia and is the president of One Mind, a mental health advocacy group based in Napa Valley.

When he and other advocates first saw Nemani’s data in early 2021, they started lobbying public health officials for priority access to the vaccines. They wanted the Centers for Disease Control and Prevention to add schizophrenia to its list of high-risk conditions for covid, as it had done for cancer and diabetes.

But they heard crickets.

“It doesn’t make any sense,” Staglin said. “Clearly, schizophrenia is a higher risk.”

In several other countries, including the U.K. and Germany, people with serious mental illnesses were prioritized for vaccines from the beginning of the rollout in February 2021. In the U.S., though, it wasn’t until people were getting boosters in October 2021 that the CDC added schizophrenia to the priority list.

“We were happy when that happened, but we wish there had been faster action,” Staglin said.

It’s always like this with mental illness, said Myrick.

“It’s like we have to remind people,” she said. “It’s just sort of, ‘Oh yeah, oh right, I forgot about that.'”

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But her excitement was short-lived. Over time, Christina’s appointments with the therapist went from every two weeks, to every four weeks, to every five or six.

“To tell somebody with serious, chronic, disabling depression that they can only see their therapist every five or six weeks is like telling somebody with a broken leg that they can only see their physical therapist every five or six weeks,” she said. “It’s not enough. It’s not even close to enough.”

Then, this summer, Christina was diagnosed with breast cancer. Everything related to her cancer care — her mammogram, biopsy, surgery appointments — happened promptly (like a “well-oiled machine,” she said), while her depression care stumbled along.

“It is a hot mess,” she said. “I need to be in therapy — I have cancer! And still nothing has changed.”

A new law signed by Gov. Gavin Newsom in October aims to fix this problem for Californians. Senate Bill 221, which passed the state legislature with a nearly unanimous vote, requires health insurers across the state to reduce wait times for mental health care to no more than 10 business days. Six other states — including Colorado, Maryland and Texas — have similar laws limiting wait times.

Long waits for mental health treatment are a nationwide problem, with reports of patients waiting an average of five or six weeks for care in community clinics, at Department of Veterans Affairs facilities and in private offices from Maryland to Los Angeles County. Across California, half of residents surveyed by the California Health Care Foundation in late 2019 said they had to wait too long to see a mental health care provider when they needed one.

At Kaiser Permanente, the state’s largest insurance company, 87% of therapists said weekly appointments were not available to patients who needed them, according to a 2020 survey by the National Union of Healthcare Workers, which represents KP therapists — and was the main sponsor of the California wait times legislation.

“It just feels so unethical,” said triage therapist Brandi Plumley, referring to the typical two-month wait time she sees at Kaiser Permanente’s mental health clinic in Vallejo, east of San Francisco.

Every day, she takes multiple crisis calls from patients who have therapists assigned to them but can’t get in to see them, she said, describing the providers’ caseloads as “enormous.”

“It’s heartbreaking. And it eats on me day after day after day,” Plumley said. “What Kaiser simply needs to do is hire more clinicians.”

Kaiser Permanente says there just aren’t enough therapists out there to hire. KP is an integrated system — it is a health provider and insurance company under one umbrella — and has struggled to fill 300 job vacancies in clinical behavioral health, according to a statement from Yener Balan, the insurer’s Northern California vice president of behavioral health.

Hiring more clinicians won’t solve the problem, said Balan, who suggested that sustaining one-on-one therapy for all who want it in the future wouldn’t be possible in the current system: “We all must reimagine our approach to the existing national model of care.”

Kaiser Permanente lodged concerns about the wait times bill when it was introduced. And the trade group representing insurers in the state, the California Association of Health Plans, opposed it, saying the shortage of therapists would make meeting the two-week mandate too difficult.

“The COVID-19 pandemic has only exacerbated this workforce shortage, and demand for these services significantly increased,” said Jedd Hampton, a lobbyist for the California Association of Health Plans, in testimony during a state Senate hearing for the bill in the spring.

Hampton referred to a University of California-San Francisco study that predicted California would have nearly 30% fewer therapists than needed to meet demand by 2028.

“Simply put, mandating increased frequency of appointments without addressing the underlying workforce shortage will not lead to increased quality of care,” Hampton said.

Lawmakers pushed back. State Sen. Scott Wiener (D-San Francisco), who authored the bill, accused insurers of overstating the shortage. State Sen. Connie Leyva (D-Chino) said that the therapeutic providers are out there but that insurers are responsible for recruiting them into their networks by paying higher rates and reducing administrative burdens.

If insurers want more young people to enter the mental health care profession, they must improve salaries and working conditions now, said state Sen. Richard Pan (D-Sacramento). (A 2016 KQED investigation uncovered multiple ways that insurers save money by keeping provider networks artificially small.)

As bipartisan support for the bill grew in Sacramento, insurers withdrew their formal opposition.

But whether other states have the political will, or the resources, to legislate a similar solution is unclear, said Hemi Tewarson, executive director of the nonpartisan National Academy for State Health Policy in Washington, D.C. Although California may be able to force insurers to hire more therapists, she said, places like New Mexico, Montana, Wyoming, and parts of the South don’t have enough therapists at any price.

“They don’t have the providers, so you could fine the insurers as much as you want, you’re not going to be able to, in the short term, make up those wait times if they already exist,” she said.

The new California law is a solid step toward improving access to mental health care, with communities of color standing to benefit the most, said Lonnie Snowden, a professor of health policy and management at the University of California-Berkeley. African Americans, Asian Americans and Latinos face the most barriers getting into care, Snowden said, and when people of color do come in for treatment, they are more likely to drop out.

Oversight and enforcement are needed for the new rules to work, said Keith Humphreys, a psychiatry professor at Stanford University. Kaiser Permanente has data systems that can track the time between appointments, but other insurers set up contracts with therapists in private practice, who manage their own caseloads and schedules.

“Who would keep track of whether people who’ve been seen once were seen again in 10 days, when it’s hard enough just to keep track of how many providers we have and who they are seeing?” he asked.

Questions like that one will fall to state regulators, primarily the California Department of Managed Health Care. The department has fined insurers $6.9 million since 2013 for violating state standards, including a $4 million penalty against Kaiser Permanente for excessive wait times for mental health care. Previous state law required insurers to provide initial mental health care appointments within 10 days, and the new law clarifies that they must do the same for follow-up appointments.

Greta Christina, who gets her care at a Kaiser Permanente facility, said she is desperate for the new law to start working. It takes effect on July 1, 2022. Christina thought about paying out-of-pocket in the meantime, to find a therapist she could see more often. But in a cancer crisis, she said, starting over with someone new would be too hard. So she’s waiting.

“Knowing that this bill is on the horizon has been helping me hang on,” she said.

This story is part of a partnership that includes  KQED, NPR and KHN.

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

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