Overview of Mental Health Services
for College Students

In this post, we provide an overview of the mental health services available to students at the University of California (UC), the California State University (CSU), and the California Community Colleges (CCC). We first describe the mental health services provided by campuses, then describe the mental health services provided by community mental health agencies. Next, we highlight recent developments in student mental health since the start of the coronavirus disease 2019 (COVID-19) pandemic. We conclude by assessing the data currently available on student mental health issues and making an associated recommendation.

Campus-Provided Services

Most Campuses Provide Student Mental Health Services. All 10 UC campuses, all 23 CSU campuses, and at least 90 out of 116 CCC campuses provide student mental health services. Campuses primarily provide short-term counseling in individual and sometimes group settings. Campus policies vary on the exact number of counseling sessions students may receive, with some campuses setting a limit (commonly between six to twelve sessions per year) and others leaving this to the discretion of counselors. Beyond counseling, other typical campus-provided services include crisis intervention (such as a hotline) for students experiencing urgent mental health concerns, as well as case management to connect students to other campus and community resources. In addition, campuses often provide various kinds of outreach on mental health issues, including trainings and workshops, peer support programs, and online resources. The exact types and levels of mental health services provided vary by segment and campus. Whereas UC campuses tend to offer the broadest array of services, including psychiatry services provided by medical doctors who are authorized to prescribe medications, CCC campuses typically offer the narrowest array of services.

Campuses Employ Mental Health Professionals to Provide Services. Campuses commonly hire various types of licensed mental health professionals, including psychologists, clinical social workers, clinical counselors, marriage and family therapists, and psychiatrists. Some campuses also have graduate- and postgraduate-level trainees, who provide mental health services under supervision. In addition, some campuses contract with third parties, including telehealth vendors, to provide or augment mental health services. Less commonly, campuses have agreements with community providers to deliver services on campus.

Campus-Provided Mental Health Services Are Largely Supported Through Student Fees. These fees are charged to the general student body, rather than to individual students utilizing the services. (Campuses typically do not charge user fees for counseling visits.) Fee levels vary by segment and campus. UC charges all students a systemwide Student Services Fee of $1,128 per academic year, which supports a broad range of services including mental health. Six UC campuses also charge additional fees for health services (including physical and mental health), ranging from $85 to $549 per academic year. CSU does not have a systemwide student services fee, but all CSU campuses charge health services fees, which range from $150 to $740 per academic year. Similarly, CCC does not have a systemwide student services fee, but districts are permitted under state law to charge health services fees of up to $44 per academic year. Most districts charge such fees, with many of them charging at or near the maximum rate.

State Has Begun Supplementing Funding for Campus Mental Health Services. As Figure 1 shows, the state has provided funding to UC, CSU, and CCC specifically for student mental health services since 2017-18. While the initial appropriations were one time, the state began providing ongoing General Fund for mental health services at UC in 2019-20 and at CSU and CCC in 2021-22. Each segment has discretion over how to allocate these ongoing funds among its campuses. The allocation methods vary by segment, but they generally account for differences among campuses in their student enrollment and demographics.

At a Small Number of Colleges, Medi-Cal Reimbursements Cover Some Costs. Eleven community colleges currently participate in the Local Education Agency Medi-Cal Billing Option Program (LEA BOP), which allows public K-12 and higher education institutions to receive federal reimbursement through Medi-Cal, the state’s Medicaid program. (Though eligible, no CSU or UC campus currently participates in the program.) Under LEA BOP, institutions are reimbursed for providing certain health services to certain Medi-Cal eligible students (those under age 22 and receiving services under an individualized care plan developed by the campus). The federal reimbursements cover at least 50 percent of the cost of providing the service, with the institution covering the remaining cost. Based on data from the Department of Health Care Services (DHCS), participating community colleges in California collectively received an estimated $23 million in federal reimbursements specifically for student mental health services in 2019-20.

A Few Other Fund Sources Support Campus Mental Health Services. Other fund sources for student mental health vary by campus and may include core campus operating funds, certain categorical programs (such as the CCC Student Equity and Achievement Program), external competitive grants, and federal COVID-19 relief funds. At UC, university-sponsored health insurance also is beginning to cover more student mental health costs. Nearly half of UC students are enrolled in the UC Student Health Insurance Plan (SHIP). (CSU and CCC do not have comparable student health insurance plans.) UC SHIP historically has been limited to psychiatry and other medical services, but two campuses recently started billing UC SHIP for student counseling services.

Systemwide Data on Mental Health Spending Is Limited. Of the three segments, only CSU has collected systemwide data on total student mental health spending. In 2020-21, CSU reports spending $45 million systemwide on mental health services, of which $30 million came from campus fees. CSU projects student mental health spending will increase to $62 million in 2021-22, primarily reflecting a $15 million General Fund augmentation.

Mental Health Staffing Levels Vary Across the Segments. Staffing ratios are one indication of the level of mental health resources, with fewer students per staff member associated with greater availability of services. The International Accreditation of Counseling Services has a commonly cited recommendation that campuses maintain a ratio of 1,000 to 1,500 students per mental health professional (commonly referred to as a “counselor”). As of fall 2020, UC’s systemwide ratio was within this range at 1,138 students per counselor. CSU’s systemwide ratio was outside this range at 1,958 students per counselor. CCC does not track this ratio, but the Chancellor’s Office indicates most colleges employ one to three mental health counselors, suggesting considerably more students per counselor than at the universities. Variations in staffing ratios among the segments and campuses may reflect differences in funding, the availability of providers, the types of services provided, and other campus characteristics (such as whether the campus primarily serves commuter or residential students).

Limited Data Is Available on Mental Health Utilization and Outcomes. Historically, only UC has tracked systemwide utilization of campus mental health services. In 2019-20, UC campuses collectively provided counseling services to about 34,000 students (12 percent of total UC enrollment) and psychiatry services to about 6,400 students (2 percent of total UC enrollment). CCC recently began collecting utilization data, reporting that about 59,000 students (2 percent of total CCC enrollment) received any mental health services in 2019-20. Across the segments, data is not available on the impact of mental health services on students’ academic or clinical outcomes. Measuring the outcomes of mental health services remains a challenge among all providers, not only college campuses. The main challenge is that academic and health practitioners have not yet developed an agreed-upon set of measurable mental health outcomes that are consistently reported.

Community-Provided Services

Students Also Can Receive Mental Health Services From Community Providers. Community providers (such as clinics and hospitals) offer mental health services to the general population, including college students. These community providers often offer similar types of clinical services as campuses, including counseling and psychiatry. County mental health departments also have a major role in the delivery of community mental health services. In particular, counties provide services for low-income individuals with the highest service needs, including Medi-Cal beneficiaries with severe mental illness. Comprehensive data is not available on (1) the total amount of community-provided mental health services for college students or (2) the amount of services provided specifically by counties for college students. Some related data, however, is available. Specifically, in 2019-20, counties provided over $400 million (across all fund sources) in Medi-Cal mental health services to Medi-Cal beneficiaries with severe mental illness who were age 18 to 24, including but not limited to college students.

Students Are Often Referred to Community Providers for Long-Term or Specialized Treatment. While some students directly seek out community providers, other students are referred by their campus. Because campus mental health services are generally intended to be short term, with the number of counseling sessions limited at some campuses, students seeking or requiring long-term treatment tend to be referred to community providers. Students are also typically referred to community providers if they have a condition that is severe or requires specialized treatment (such as an eating disorder, attention deficit hyperactivity disorder, or substance abuse). Campuses commonly maintain directories of community providers for referral purposes. Some campuses also provide additional support to students with the referral process, such as helping students make phone calls to providers or navigate their health insurance coverage. Campuses vary in terms of the availability of providers in their local community and the strength of their relationships with those providers. None of the segments collect comprehensive data on the volume of referrals to community providers.

Students Typically Use Health Insurance for Community-Provided Services. Unlike campus providers, community providers typically charge for services. As Figure 2 shows, most students in California attending public or private higher education institutions have health insurance to help cover these costs. Students typically receive health insurance through their or their parent’s employer, Medi-Cal, or the individual market. (The individual market is where people purchase coverage directly from insurers, including through the Covered California health benefits exchange.) Although students commonly have insurance coverage, they may still face barriers to accessing community providers—including finding a local provider that accepts their insurance, covering the cost of co-pays, and getting transportation to appointments.

Recent Developments

Student Mental Health Concerns Have Continued to Increase During Pandemic. Historical data suggests the prevalence of mental health issues among college students nationally has increased over the long term. More recent data suggests the COVID-19 pandemic exacerbated this trend. Since the onset of the pandemic, several studies have found further increases in a variety of student mental health issues. For example, a study from the Healthy Minds Network (a research organization focused on the mental health of young adults) indicates that the prevalence of depression among college students nationally increased from 36 percent in fall 2019 to 41 percent in spring 2021, while the prevalence of anxiety increased from 31 percent to 34 percent.

Campus Mental Health Utilization Decreased at Start of Pandemic, but Could Grow as Campuses Reopen. Despite the increase in the prevalence of mental health issues among college students, national data suggests the use of campus mental health services declined at the onset of the pandemic. As Figure 3 shows, this decline similarly occurred at UC, the only segment that systematically reports utilization data. The decline likely was related to campus closures beginning in March 2020, which required campuses to rapidly transition to providing mental health services through telehealth. In discussions with our office, stakeholders noted that while some students prefer the convenience of telehealth services, others face barriers to accessing telehealth or prefer the face-to-face interactions of in-person visits. Some students may also have sought community-provided services during their time off campus. With campuses delivering more instruction and other activities in person in 2021-22, many campuses anticipate an increase in utilization of campus mental health services. Systemwide utilization data for 2021-22 is not yet available, but anecdotally some campuses indicate an unusually high influx of students seeking counseling early in the fall 2021 term.

2021-22 Budget Provided Significant Augmentations for Student Mental Health. The 2021-22 state budget included the following actions:

• Ongoing Funding to CCC, CSU, and UC. The budget provided $30 million ongoing Proposition 98 General Fund to CCC, $15 million ongoing General Fund to CSU, and $15 million ongoing General Fund to UC for student mental health services. Provisional language requires CCC to report every three years and CSU and UC to report annually on these funds, including how the funds were distributed among and used by campuses.

• Partnership, Capacity, and Infrastructure Grants. The budget provides $30 million one-time General Fund in 2021-22 and $120 million one-time General Fund in 2022-23 to DHCS for grants to build partnerships, capacity, and infrastructure supporting behavioral health services for CCC, CSU, and UC students. DHCS is to award the grants through a competitive process to higher education institutions and other eligible entities (such as counties, community-based organizations, and health insurance plans). As of this writing, the process and time line for awarding these grants had not yet been determined. These grants are part of the broader Children and Youth Behavioral Health Initiative.

• Other Behavioral Health Support for Young Adults. Beyond the grants targeted toward college students, the Children and Youth Behavioral Health Initiative provides an additional $4.2 billion in total funds across five years for numerous other efforts supporting the broader population of individuals age 25 and under. These efforts include creating more online behavioral health resources, expanding the behavioral health workforce, implementing evidence-based interventions, and launching a public education campaign to raise awareness of behavioral health issues.

• New Requirement for Health Insurance Plans. Trailer legislation to the budget requires health insurance plans to begin covering medically necessary behavioral health services provided at school sites—including CCC, CSU, and UC campuses—effective January 1, 2024. State law defines “medically necessary” to refer to services that address the specific needs of the patient and meet certain conditions, including being clinically appropriate and in accordance with generally accepted standards of care. Many services that campuses provide likely meet this definition.

Conclusion

State Lacks Adequate Data to Guide Future Decisions. Given recent state augmentations and continued interest in this area, the Legislature will likely want to monitor student mental health services more closely in the coming years. Consistent reporting, however, is lacking in several key areas. For example, only UC systematically tracks data on the utilization of campus mental health services, whereas only CSU tracks total spending on these services. Recently, CCC has collected some utilization data, but it has not yet collected data on spending or staffing. Moving forward, the Legislature will need more comprehensive, consistent information to assess whether the recent augmentations are improving access to mental health services, whether future augmentations are warranted, and how those future augmentations should be targeted.

Recommend Expanding Mental Health Reporting Requirements at UC, CSU, and CCC. The 2021-22 budget contains provisional language outlining new reporting requirements, which we believe serves as a promising starting point. This provisional language is linked with ongoing state funding for student mental health services at UC, CSU, and CCC, and it requires all three segments to submit recurring reports on the use of these funds. We recommend the Legislature expand on these reporting requirements to collect a more comprehensive, consistent set of data on student mental health services supported by all fund sources. Specifically, we recommend requiring the segments report the data listed below. Nearly all of the data elements listed already are collected by some campuses, and many are collected systemwide by at least one of the segments.

• Unduplicated number of students receiving campus mental health services, disaggregated by race/ethnicity, gender, age group, source of insurance coverage, and type of service received.

• Average wait time for initial routine counseling appointments.

• Average number of campus mental health counseling appointments per student.

• Number of students referred to community providers for mental health services.

• Total spending on student mental health services, by fund source.

• Number of student mental health staff by provider type and counselor-to-student ratio.