David Mineta gets emotional when he talks about his organization’s decision to close six mental health programs serving about 650 children and adults in Santa Clara County by the end of December.
“Talking about it really makes me want to cry,” he says.
Depending on who you ask, these mental health program closures are either an unfortunate aberration or a harbinger of more to come as the state transforms its Medi-Cal reimbursement system.
Venegas, executive director of Changing Tides Family Services in Eureka, and Mineta, president and CEO of Momentum For Health in San Jose, say their organizations are being forced to cut crucial mental health programs in order to keep the rest of their agencies afloat. They attribute that to CalAIM, a multi-year, multi-billion-dollar overhaul of Medi-Cal that dramatically changes how California’s public mental health care programs are funded.
“I would love to invite Gov. Newsom and his team to come talk about what CalAIM is in an area like ours,” Venegas said. “Instead of making it better, I really think this has made it worse.”
CalAIM’s behavioral health initiative, which Gavin Newsom’s administration began rolling out in 2022, is designed to provide a more integrated approach to care. It offers a “no wrong door approach” so that people seeking help will have an easier time getting it.
This past July, a new payment system kicked in for most counties. The goal? Increase efficiency, reduce paperwork and offer counties more flexibility.
The problem, some nonprofits say, is that their organizations are no longer reimbursed specifically for time spent traveling to see patients or filling out documentation. In addition, the state is giving counties latitude to decide how much Medi-Cal money they pass along to their nonprofit behavioral health contractors.
Los Angeles County is passing along about 85 percent of the funds it receives from the state, according to Adrienne Shilton, a senior policy advocate with the California Alliance of Child and Family Services, while others are providing less.
She shared survey data showing nonprofits in a dozen counties told the alliance they worried they might have to close programs.
“There’s still a dire picture,” Shilton said. “We’re concerned about what this is going to look like in another three months.”
Amie Miller, executive director of the California Mental Health Services Authority, a state agency that works with counties to transform mental health services, said she hasn’t heard of programs closing directly as a result of payment reform.
Some providers are struggling with longstanding financial problems, Miller said, and others are “used to not having to be as attentive to the bottom line.”
“This is the next piece of our evolution,” she said.
Some providers have said they stand to do well under the new model, she added.
Still, some nonprofit organizations have been sounding the alarm since summer that the rates are too low and eventually will lead to program closures.
Dozens of mental health providers in October penned a letter to the state Department of Health Care Services, warning of “potentially catastrophic consequences.”
It’s a familiar story by now, but one that has become perhaps more confusing with time because of changing public health recommendations, new vaccine boosters and our evolving understanding of the virus.
There’s no reason to panic, state epidemiologist Dr. Erica Pan said, with population immunity at high levels.
“Over the course of the last three-and-a-half years, we’re fairly sure everybody’s been exposed or vaccinated at least once, or exposed and infected whether they knew it or not,” Pan said. “There’s thankfully a lot more immunity overall.”
The test positivity rate has been growing steadily over the past two months, increasing about 8 percentage points since July to a 12.5 percent seven-day average. That’s a higher positivity rate than last winter’s surge, although testing data has become less reliable as access decreased and testing rates plummeted. But wastewater surveillance networks confirm what the testing data suggests: COVID-19 infections are on the rise across California.
The second indicator of COVID-19’s comeback — hospitalizations — is also trending upward. The number of daily new hospital admissions increased more than 87 percent since the start of summer.
The Labor Day holiday will surely fuel more transmission and hospitalizations, but hospitals are nowhere near the brink of collapse that previous surges threatened. The uptick in cases is not having a “dramatic impact on hospitals” so far, California Hospitals Association spokeswoman Jan Emerson-Shea said.
Still, public health experts recommend people take the typical precautions to prevent a serious outbreak: vaccinate, mask and isolate.
“Some people are very terrified. Most people are not thinking about (COVID-19) at all. The right answer is somewhere in between,” said Dr. Peter Chin-Hong, an infectious disease specialist at UCSF Health. “At the minimum we have enough tools to have individual protection without having mandates.”
If you’re wondering what the latest uptick means, you’re not alone. Here are answers to common questions.
The U.S. Environmental Protection Agency’s investigation was triggered by a complaint filed by tribes and environmental justice organizations that says the the water board for over a decade “has failed to uphold its statutory duty” to review and update water quality standards in the Bay-Delta.
“It’s pretty bad when California Indians have to file a complaint with the Federal Government so that the State doesn’t violate our civil rights,” Gary Mulcahy, government liaison for the Winnemem Wintu Tribe, said in a statement.
The water board has allowed “waterways to descend into ecological crisis, with the resulting environmental burdens falling most heavily on Native tribes and other communities of color,” the complaint says.
The groups also said the state agency “has intentionally excluded local Native Tribes and Black, Asian and Latino residents from participation in the policymaking process associated with the Bay-Delta Plan,” according to an EPA letter to the state dated Tuesday.
Jackie Carpenter, a spokesperson for the water board, said the agency will cooperate fully and “believes U.S. EPA will ultimately conclude the board has acted appropriately.”
“The State Water Board deeply values its partnership with tribes to protect and preserve California’s water resources. The board’s highest water quality planning priority has been restoring native fish species in the Delta watershed that many tribes rely upon,” Carpenter said in an emailed statement.
The drought-prone state has turned to recycled water for more than 60 years to bolster its scarce supplies, but the current regulations require it to first make a pit stop in a reservoir or an aquifer before it can flow to taps.
The new rules, mandated by state law, would require extensive treatment and monitoring before wastewater can be piped to taps or mingled with raw water upstream of a drinking water treatment plant.
“Toilet-to-tap” this is not.
Between flush and faucet, a slew of steps are designed to remove chemicals and pathogens that remain in sewage after it has already undergone traditional primary, secondary and sometimes tertiary treatment.
It is bubbled with ozone, chewed by bacteria, filtered through activated carbon, pushed at high pressures through reverse osmosis membranes multiple times, cleansed with an oxidizer like hydrogen peroxide and beamed with high-intensity UV light. Valuable minerals, such as calcium, that were filtered out are restored. And then, finally, the wastewater is subjected to the regular treatment that all drinking water currently undergoes.
“Quite honestly, it’ll be the cleanest drinking water around,” said Darrin Polhemus, deputy director of the state’s Division of Drinking Water.
The 62 pages of proposed rules, more than a decade in the making, are not triggering much, if any, debate among health or water experts. A panel of engineering and water quality scientists deemed an earlier version of the regulations protective of public health, although they raised concerns that the treatment process would be energy-intensive.
“I would have no hesitation drinking this water my whole life,” said Daniel McCurry, an assistant professor of civil and environmental engineering at the University of Southern California.
This water is expected to be more expensive than imported water, but also provide a more renewable and reliable supply for California as climate change continues. Most treated sewage — about 400 million gallons a day in Los Angeles County alone — is released into rivers, streams and the deep ocean.
The draft rules, released on July 21st, still face a gauntlet of public comment, a hearing and peer review by another panel of experts before being finalized. The State Water Resources Control Board is required by law to vote on them by the end of December, though they can extend the deadline if necessary. They would likely go into effect next April and it will take many years to reach people’s taps.
Since the COVID-19 pandemic began, the number of nurses at the hospital dropped from just below 500 to 330 according to her union’s roster, said Hooks, who is 53.
“It wasn’t even this difficult during the height of the COVID pandemic,” she said.
Hooks’ stress reflects pressure many California nurses are under because of steep understanding that she and others say is driving many professionals out of the industry.
According to the Hospital Association of Southern California, nursing vacancy rates among local hospitals exceed 30 percent. Prior to the pandemic the average vacancy rate was 6 percent.
“Within the last year and a half or so, it’s really gotten worse,” Hooks said.
Now the Legislature is looking at several ideas to address the nursing shortage by bringing more early-career nurses into the field. But so far, the groups with most to gain — or lose — are at odds over how to solve the staffing problems afflicting California’s health care workforce.
Labor organizations and hospitals want nursing schools to prioritize certain applicants for admission, such as people who already have experience in the industry.
“We don’t have enough nurses entering the system as opportunities are opening up for them to leave the system,” said Peter Sidhu, a nurse and executive vice president of United Nurses Associations of California/United Health Care Professionals.
But the schools say that won’t help them graduate more nurses. They need more faculty and more hands-on training opportunities to increase class sizes.
Hospitals and unions say they don’t have much time to waste. Estimates show California faces a shortage of about 36,000 licensed nurses, according to the UC San Francisco Health Workforce Research Center on Long-Term Care.
The state’s COVID-19 workplace rules protecting workers’ rights to decide for themselves whether to wear face coverings are locked in at least until February 2025 and could be extended.
Those regulations prevented the iconic Irvine-based burger chain from applying its new policy prohibiting workers from wearing face masks in its home state, where it operates about 70 percent of its restaurants.
Instead, In-N-Out’s mask ban will apply to workers at its restaurants in Arizona, Colorado, Nevada, Texas and Utah. It has a total of 116 locations in those states.
In a memo, the company said it wants to “emphasize the importance of customer service. And the ability to show our Associates’ smiles and other facial features.”
It is allowing employees to wear masks if they present a medical note that “clearly states the reason for the exemption.”
In-N-Out released a different masking policy for employees in California and in Oregon that leaves the choice to mask up to each individual worker. That approach complies with California and Oregon standards that provide continuous protections to employees.
In a way, the split is a reminder of California’s more cautious response to the COVID-19 pandemic. The Democratic state was the first to order its residents to shelter in place and shut down non-essential activity. Throughout the pandemic, state health officials have updated guidelines and rules to adapt to evolving transmission patterns.
In-N-Out went along with those rules during the pandemic, although the company contested local indoor vaccine mandates in the fall of 2021. Its refusal to check customers’ vaccination records led to temporary shutdowns of restaurants in San Francisco and in Pleasant Hill of Contra Costa County, according to press reports.
Cal/OSHA, the agency charged with ensuring occupational safety in California, earlier this year updated its COVID-19 requirements. Among them: “Employers must allow employees to wear face coverings if they voluntarily choose to do so, unless it would create a safety hazard.”
The nursing homes in question are owned by Los Angeles businessman Shlomo Rechnitz, who owns dozens of California facilities through a web of companies, including Humboldt County's four primary skilled nursing facilities.
One of his main companies, Brius Healthcare, has been scrutinized for poor quality care and inadequate staffing, according to federal and state inspection reports, plaintiffs’ attorneys and press accounts. By 2015, government regulators decertified or threatened to decertify three of Rechnitz’s companies’ California nursing homes, a rare penalty that strips facilities of crucial Medicare and Medi-Cal funding.
One of those facilities, Wish-I-Ah Healthcare & Wellness Centre near Fresno, was closed following the death of a 75-year-old resident from a blood infection after staff left behind in her body a foam sponge used in dressing her mastectomy wound. Investigators also found toilets brimming with fecal matter and other serious problems, according to the state’s accusation.
The State Auditor’s office in a May 2018 report spotlighted Brius for its higher rate of federal deficiencies and state citations, compared to the rest of the industry in the state.
It was via bankruptcy court that Rechnitz scooped up 18 Country Villa-branded nursing homes in 2014. Per state law, he then filed change-of-ownership applications seeking licenses to run those homes. The state didn’t approve or deny them, instead leaving them pending. In the meantime, Rechnitz continued to run the nursing homes for years without a formal license in his name – which isn’t technically illegal.
A new law was supposed to close that loophole. But that law, co-authored by Democratic Assemblymembers Al Muratsuchi of Los Angeles and Jim Wood of Santa Rosa, doesn’t go into effect until July 1 — and it focuses on new license applications, rather than those that have been operating in the legal gray area for years.