In rural Redding, California, between Sacramento and the Oregon border, many students arrive at primary schools anxious or angry or not having eaten or slept. Children and adults in the region were reported to have higher rates of traumatic experiences than those in any other part of the state. Schools can provide students food, a place to rest and clinics for vision, hearing and dental care, as well as vaccines. But one medical intervention — therapy — is limited, despite widespread student interest.
Audrey Cutler sees the need for student therapy. A licensed clinical social worker, she is a counselor at Mistletoe School, a public elementary school in Enterprise Elementary School District in Redding. Cutler has 60 students whom she formally counsels but makes herself available to the 690 students on campus, she said.
Like Cutler, Nichole Sandefur is a counselor and provides therapy at nearby Parsons Junior High School, a public middle school in Enterprise school district. A licensed marriage and family therapist, Sandefur meets regularly with fewer than a dozen students, but by midmorning on a typical day, she will have received requests for help from many more students, teachers and administrators.
A law requiring insurance companies to pay for student therapy at schools could help Redding’s students as well as Cutler, Sandefur and their colleagues in the district. Aid might begin soon; last month, Kelly Pagan, the Enterprise district’s head nurse, said she submitted Shasta County’s first student therapy bill to Anthem Blue Cross of California, a local healthcare provider through Covered California. All California students could benefit from her lead.
School-based therapy may be more accessible for all students this year because of Assembly Bill 133, a 2021 law that requires insurance providers to reimburse schools for “outpatient mental health or substance use disorder treatment provided to a student 25 years of age or younger at a school site.”Schools that enroll kindergartners and elementary, middle school, high school and college students are all eligible for reimbursement under a provision of the new law. Known as the “fee schedule change” among health care providers, the provision was part of the 2021-’22 omnibus health trailer bill, a package of changes meant to improve health care for young people.
The law also required the California Department of Health Care Services to create a billing system to make reimbursements easier for schools providing therapy and counseling.
A cohort of 47 school districts across the state volunteered to test and implement the new billing system last year. That includes some of the largest in the state — Los Angeles Unified School District, San Diego Unified School District — as well as smaller school districts such as Enterprise Elementary School District, where Pagan works. Schools could see the benefits this year after months of testing the system.
The law and funding mechanism to provide better therapy services for California students is part of the Children and Youth Behavioral Health Initiative, a $4 billion state effort to address the increasing rates of anxiety, depression, stress and self-reported trauma among the state’s young people following the COVID-19 pandemic.
“If this really comes to fruition like it should, we will support kids tenfold,” Pagan said.
In a place like Redding, it can be difficult for families to get to clinics or doctor’s visits, even when they have health insurance, Pagan said. They may not have the money for such visits, which also require either bus fare or gasoline for the car trip. And there’s another cost: Many adults cannot afford to take time off work to ferry their children to a doctor, she added. More than 71% of Enterprise Elementary School District’s approximately 3,400 children are socioeconomically disadvantaged and qualify for free or reduced-cost school meals. The median household income in Shasta County is nearly $72,000, according to the U.S. Census Bureau, and the county estimated that the percentage of people living below the local poverty level is higher than the state’s.
Given the circumstances in Shasta County and Redding, schools are the most logical place for children to receive care, including therapy and counseling, Pagan said. But providing therapy at school requires removing the barriers to insurance reimbursements for schools to pay for counseling or hiring outside help.
In the past, California students seeking mental health support — individual therapy or counseling — largely relied on referrals through their primary care doctor. In some cases, students could qualify for therapy at school if it were prescribed in an Individual Education Plan, or IEP. But that method has its own problems with funding and insurance reimbursement. And not every student has an IEP.
Schools often employ licensed social workers who can offer therapy. But in the past, insurance companies would not pay for the service if the social worker was not an authorized provider. In many cases, school administrators took a financial loss to offer students therapy or had to make cuts in other student services to make up for the cost, Pagan explained.
When Pagan applied for Enterprise Elementary School District to be part of the first group of school districts to offer therapy at school through the fee schedule change, she cited Shasta County’s high rates of childhood trauma.
A groundbreaking California study 30 years ago found that childhood trauma often led to mental and physical health needs as adults. Adverse childhood experiences included “Seven categories of adverse childhood experiences were studied: psychological, physical, or sexual abuse; violence against mother; or living with household members who were substance abusers, mentally ill or suicidal, or ever imprisoned.”
The far north and north coast regions of California — including Del Norte, Humboldt, Lake, Mendocino, Modoc, Shasta, Siskiyou and Trinity counties — had the highest reported rates of adults and children with multiple traumatic childhood experiences, according to the California Department of Health Care Services’ research from 2020 to 2023.
For counselors Cutler and Sandefur, attending to student mental health is a daily practice of keeping student appointments and making themselves available to others.
At Mistletoe School, Cutler works with children as young as 4 (transitional kindergartners) and as old as teens in eighth grade. Cutler’s work begins before class starts. Some students arrive by bus before school doors open at 7:30 a.m., so Cutler brings them into her office and checks in with them. Many students arrive having not slept or eaten. Many families have low incomes. Witnessing drug and alcohol abuse at home is common. Anxiety and anger often stems from what’s happening at home. In the classroom, this can lead to cursing at teachers or flipping chairs.
Cutler has a counseling caseload of 60 students, but in reality, she said, she makes herself available to all of the school’s 690 students.
When Sandefur arrives each morning at Parsons Junior High, she checks in with colleagues to see if there were any overnight crises reported by law enforcement or social services agencies. She then walks through campus, talking with students in the cafeteria, on the patio and even in the bathrooms. Sandefur said this sets the pace for her day. Her morning rounds allow her to identify any students who might need to talk with her.
She then prepares to meet students who need intervention or short meetings and check-ins. At those meetings, she helps students plan for a successful day of positive interactions with teachers. By midmorning, Sandefur will have received additional counseling requests from students, teachers and administrators.
Sandefur runs small groups with students to improve their behavior. She also runs vape education groups — akin to adult rehab groups — for students using the electronic cigarettes.
The fee schedule change could bring specific improvements to the small district in rural Northern California. Insurance funding for therapy and counseling means principals and school districts won’t have to cut services such as therapy because of limited school finances that change annually.
Pagan said that insurance reimbursements will allow the district to contract reliably with outside therapists without cutting funds for other programs. The district could also pay its licensed counselors more or increase wages to attract more qualified counselors. Addressing mental health needs in the same way as physical health needs such as dental and vision care and vaccines will improve student academic achievement.
For students, the insurance money will allow for undivided one-on-one attention from a therapist. Without it, Cutler cannot get to all her students in a single day, she said, nor offer them the attention they need.
A school-centered model of health support in places such as Redding and Shasta County is crucial to improving public health: physical, emotional and mental, Pagan said. Providing services at school, where children are at least four hours a day, removes a family’s challenge of getting them to a doctor’s office. Providing insurance reimbursement for school-based mental health care moves California students closer to mental health equity with the rest of the population. And if schools in Redding can figure it out, so can the rest of California.
This article was produced as a project for the USC Annenberg Center for Health Journalism’s 2024 California Health Equity Fellowship.
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