Keynote: Sup. Nathan Fletcher on polarization, BH reform, and health care privatization


Eli Kirshbaum


We were honored to host Sup. Nathan Fletcher as the Lunch Keynote speaker at last week’s 2021 Southern California State of Reform Health Policy Conference. The chair of the San Diego Board of Supervisors offered his thoughts on political polarization, behavioral health integration in San Diego County, and the county’s “messy” Medi-Cal managed care (MMC) reprocurement process.


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A strong advocate for behavioral health reform, Fletcher said behavioral health should just be considered a part of “health.” He criticized the county’s siloed behavioral health care system and called for its integration with physical health. Achieving this, he said, will require addressing the stigma surrounding behavioral health.

“We don’t view it as health. We don’t fund it, staff it, cite it, reimburse it, we don’t workforce it … And a lot of that is the stigma that is associated with issues of mental health illness.”

He said the county should prioritize mobile crisis response teams, person-centered care units, and crisis stabilization units and have a coordinated behavioral health care system that “flips the paradigm” and provides continuous care to support full recovery. He also emphasized the importance of harm reduction initiatives, calling the non-unanimity of the Board’s January vote to implement a county needle exchange program “crazy.”

Fletcher praised CalAIM’s community supports (formerly “In Lieu of Services”) initiative, calling it “potentially transformative.” He was critical, however, of San Diego County’s seven-plan MMC structure.

“Every provider out there knows it’s a mess. You’ve got seven forms, you’ve got seven different systems, and there’s not consistency in what’s covered–it doesn’t work.”

He said San Diego’s MMC system doesn’t make sense and that data shows it isn’t proving as effective as other counties’ two-plan system. He nonetheless believes that when CalAIM and reprocurement are finished, the county will “be in a much better position.”

Fletcher also shared his belief that while privatization has its place in health care, many health services are much better off publicized.

“There are places where the profit motive works and [where] the market works. And I believe in the market. I believe in competition … But there are places where it is a public responsibility and a public role, and I’d rather have it done by public workers.

I don’t just universally think competitive, profit-based systems are inherently always the way to go when it comes to health care.”

See the video above for Fletcher’s full remarks.