Improving Mental Health Care for the “Missing Middle”

Challenges with mental health and addiction affect us all, and the number of people struggling only intensified during the pandemic. In 2021, for example, 37% of the U.S. adult population suffered from moderate to severe anxiety, up from 7% in 2019, according to the Century Foundation.

Here in Los Gatos, a recent survey from our friends at SASCC (Saratoga Area Senior Coordinating Council) found that about 30% of residents over age 60 live with depression, and 80% said they do not have access to quality mental health care.

That’s simply not acceptable. Mental health care is health care. Folks should have access to it at every phase of life, no matter what their income or resources may be.

Yet, affordability is a huge barrier, even for those who earn what most of us would consider a decent living. Many West Valley residents fall into what I call the “missing middle” – people who earn a bit too much to qualify for Medi-Cal subsidies but not enough to pay for care out of pocket. Having commercial health insurance is no guarantee, since many plans don’t offer adequate coverage.

Whatever the case, the mental health needs of the missing middle have been overlooked for far too long. We need to close the gap that has allowed too many people to slip through the cracks in our health care system.

As Chair of Santa Clara County’s Health and Hospital Committee (HHC), I’m pleased that the County is making real progress in doing just that.

First, the Board of Supervisors unanimously supported my proposal to ensure that residents are aware of their “mental health parity” rights. Under state law, medically necessary treatment for all mental health and substance use disorders must get equal treatment with other health conditions.

California Senate Bill (SB) 855 expanded this right in 2020, prohibiting health plans and insurers from limiting these benefits to short-term or acute treatment. But not all insurers are stepping up as they should. And many patients are not aware of their rights. People often spend a lot of time trying to figure it all out, worrying if their insurance covers the services, and working out how to pay for it all.

At this month’s HHC meeting, we’ll be considering options to improve mental health parity in the County, including an education and outreach campaign to ensure that residents are aware of their rights under state law.

Second, at my request, the County is developing a program that ensures mental health treatment for middle income residents, that missing middle I’m talking about.

Accessible and affordable outpatient services are essential to avoiding the high costs and societal harms from inpatient treatment, hospitalization, or a lack of treatment. Some individuals receive these services from public programs, others use commercial insurance. But coverage options are often imperfect, due to high out-of-pocket costs and a decline in the number of mental health professionals accepting public insurance.

I’m encouraged as well by how much mental health has become part of the everyday conversation. Last month, SASCC brought its annual health fair back from pandemic hiatus, focusing on mental health.

What I loved is that the event wasn’t tucked away in a corner somewhere. We gathered in front of Los Gatos High School’s beautiful Neoclassical style building, a place everybody in the community knows. That’s the way we ought to be talking about these issues, right out front, right in public, no stigma attached.

Because we have to face up to the fact that people in need aren’t getting the help they need and deserve.

I think we’ve finally turned a corner in understanding the role we have to play, whether it’s for young people who need help, or programs that help families and seniors in the “missing middle” get affordable outpatient mental health services.

Every one of us can make a difference. We can start by getting the word out about the resources that are now available, by advocating for more, and by doing everything we can to help make folks feel welcome, valued, and connected. It’s good for patients, good for families, and good for our entire community.

Joe Simitian
Santa Clara County Board of Supervisors

This article was originally published in The Outlook in October 2022.