California expands insurance access for teens seeking therapy on their own

When she was in ninth grade, Fiona Lu fell into a depression. She had trouble adjusting to her new high school in Orange County and felt so isolated and exhausted that she cried every morning.

Lu wanted to get help, but her Medi-Cal plan wouldn't cover therapy unless she had permission from a parent or guardian.

Her mother — a single parent and an immigrant from China — worked long hours to provide for Fiona, her brother and her grandmother. Finding time to explain to her mom what therapy was, and why she needed it, felt like too much of an obstacle.

"I wouldn't want her to have to sign all these forms and go to therapy with me," says Lu, now 18 and a freshman at UCLA.

"There's a lot of rhetoric in immigrant cultures that having mental health concerns and getting treatment for that is a Western phenomenon."

By her senior year of high school, Lu turned this experience into activism. She campaigned to change the state policy to allow low-income teens age 12 and up to get mental health counseling without their parents' consent.

In October, Gov. Gavin Newsom signed a new law making that change for young patients covered by Medicaid (called Medi-Cal in California.)

Teens covered by commercial insurance have had this right in California for more than a decade. But it was their parents who were among the most vocal in opposing the extension of that right to youth covered by Medi-Cal.

Many of these parents seized on the bill as an opportunity to air their grievances about how much control the state has over their children, especially in the area of gender identity and care.

One mother went on Fox News last April, calling school therapists "indoctrinators," and saying the bill allowed them to fill kids' heads with ideas about "transgenderism" without their parents knowing.

Those ideas were then repeated on social media and at protests held across California and in other parts of the country in late October.

Within the state Capitol, several Republican lawmakers voted against the bill, AB 665. One of them was Assemblymember James Gallagher from Sutter County.

"If my child is dealing with a mental health crisis, I want to know about it," Gallagher said while discussing the bill on the Assembly floor last spring.

"This misguided and, I think, wrongful trend in our policy now, that is continuing to exclude parents from that equation and say they don't need to be informed, is wrong," Gallagher added.

State lawmaker salaries are set by statute and are too high to qualify them or their families for Medi-Cal. They are offered a choice of 15 commercial health insurance plans as part of their employment, so children like Gallagher's already have the rights he objected to in his speech.

To Lu and other low-income youth, this was frustrating and hypocritical. They felt like the opponents lining up against AB 665 at all the legislative hearings were mostly white and middle-class parents trying to hijack the narrative.

"It's inauthentic that they were advocating against a policy that won't directly affect them," Lu says. "They don't realize that this is a policy that will affect hundreds of thousands of other families."

Sponsors of AB 665 presented the bill as a common-sense update to an existing law. Back in 2010, California lawmakers had made it easier for youth to access outpatient mental health treatment and emergency shelters without their parents' consent, by removing a requirement that they be in immediate crisis.

But at the last minute, lawmakers cut out teens covered by Medi-Cal for cost reasons, because of an ongoing recession. More than a decade later, AB 665 was meant to close the disparity between insurance types, and level the playing field for all kids.

"This is about equity," says Assemblymember Wendy Carrillo, the bill's author, a Democrat from Los Angeles.

The original law, which regulated private insurance plans, passed with bipartisan support, and had no opposition, she says, and was signed by a Republican governor, Arnold Schwarzenegger.

"Since then, the extremes on both sides have gotten so extreme that we have a hard time actually talking about the need for mental health," she says.

After Carillo introduced the bill this year, her office faced death threats. She says the goal of the law is not to divide families but to encourage dialogue between parents and children and to rely on counseling to facilitate that.

More than 20 other states allow youth to consent to outpatient mental health treatment without their parents' permission, including Colorado, Ohio, Tennessee, and Alabama, according to a 2015 paper by researchers at Rowan University.

To opponents like San Francisco Bay area attorney Erin Friday, AB 665 is an incremental piece of a broader campaign to take parents' rights away in California, something she opposes regardless of what kind of health insurance kids have.

Friday is a self-described life-long Democrat who voted for same-sex marriage. But then she discovered her teenager had come out as transgender at school and was being referred to by a different name and pronouns by teachers for months, without her knowledge. She devoted herself to fighting any and all bills that she saw as promoting "transgender ideology." She plans to sue California to try to overturn the most recent law, before it takes effect this summer.

"We're giving children autonomy they should never have," Friday says.

Under the law, youth will be able to talk to a therapist about gender identity without their parents' consent. But they cannot get residential treatment, medication or gender-affirming surgery without their parents' okay, as some opponents have suggested.

Nor can youth run away from home or emancipate themselves under the law, as opponents have also suggested.

"This law is not about inpatient psychiatric facilities. This law is not about changing child custody laws," says Rachel Velcoff Hults, an attorney with the National Center for Youth Law, which sponsored AB 665.

"This law is about ensuring when a young person needs counseling or needs a temporary roof over their head to ensure their own safety and well-being, that we want to make sure they have a way to access it," Hults says.

Removing the parental consent barrier could also expand the number of mental health clinicians in California willing to treat youth on Medi-Cal.

Without parental consent, under the old rules, clinicians couldn't get paid by Medi-Cal for the counseling they provided, either in a private practice or a school counselor's office.

Esther Lau, now 18, struggled with mental health as a high schooler in Fremont. Unlike Lu, she had her parents' support, but she still couldn't find a therapist who accepted their Medi-Cal coverage. She was the only native English speaker in her family, and had to navigate the bureaucracy of the health system on her own.

For her, AB 665 will incentivize more clinicians to accept more low-income youth into their practices.

"For the opposition, it's just about political tactics and furthering their agenda," Lau says. "The bill was designed to expand access to Medi-Cal youth, period."

This story comes from NPR's health partnership with KQED and KFF Health News.