The Brief

After M graduated from high school in California, she got a job at a fast food restaurant making burgers. Her coworkers were chatting over the fryer one day when M got a weird feeling, like somehow they knew what she was thinking. It was like her coworkers could read her mind and were discussing her thoughts with each other.

"I was like, are they talking about burgers or are they talking about me?" says M, now 21. NPR has agreed to identify M by her middle initial because she fears the stigma around her mental illness could disrupt her career path.

There was one coworker in particular, a guy she had a crush on, and she was pretty sure he was watching her. She suspected he hacked into her phone so he could listen to her conversations, find out where she was and follow her around. If she was walking down the street, or hanging out in the park, she saw him. Her mom remembers M wanted to sleep with the lights on, repeatedly asking her through the night, "Mom, is someone here?"

A crisis, a hospital stay, a rare referral

One day, her mom said M got so paranoid, so scared, she locked herself in the bathroom and just screamed and screamed and screamed.

Her mom wanted to call for help. But she didn't have a job at the time. This was about a year into the pandemic, and the hotel where M's mom worked had been closed since the first lockdown. When she lost her job, she lost her family's health benefits, too. "My husband was like, 'What is that going to cost?'" her mom remembers.

M's mom called 911 anyway. In the hospital, M was diagnosed with schizophrenia and within a few weeks she was enrolled into a specialized two-year outpatient treatment program at the Felton Institute near San Francisco. Her relatively quick path into effective treatment is highly unusual for patients like her.

M is one of 100,000 young adults or adolescents who have a psychotic episode every year in the US. A psychotic episode is characterized by hallucinations, like hearing or seeing things that are not there; delusional beliefs; and paranoia.

On average, it takes people a year and a half to get into meaningful treatment, if they ever do at all. About 80 to 90% of affected young people inch through the country's fragmented mental health care system, many struggling to find a clinician with adequate training in psychosis.

Only 10 to 20%, including M, find space in one of the holistic treatment programs recommended by the National Institute of Mental Health as the gold standard of care for early psychosis. That's because these programs rarely have enough slots available for the people who need there, and because health insurance companies typically refuse to cover the full cost of these programs, even when they are available.

But M is considered one of the lucky ones. Through her state-based public insurance, she never paid a dime for any of the care she received at the Felton Institute's early psychosis program.

A suite of wrap-around services

For two years, M was surrounded by a team of providers looking out for every aspect of her well-being, including a physician, who prescribed antipsychotic medications and a psychotherapist, who did weekly therapy with M to work through her paranoia and delusions.

But the program also provided an occupational therapist, who would go with M to the gym, or coach her through conflicts she had with her friends; a peer specialist who had also been through psychosis and could relate on a personal level; a family support specialist who worked with M's mom; and an education and employment specialist, who helped M look for a job.

Treatment that leads to independence and a career

At first, M wasn't interested in work. Her new medications made her really tired. Fatigue is a common side effect of antipsychotics, and that was layered on top of her already low motivation, which is a common symptom of schizophrenia.

"Since I didn't really have anything to do, I would just take super long naps during the day," M recalls.

But then she met Monet Burpee, Felton's job coach. On a typical workday, Burpee will drive her clients to the local mall or downtown shopping district, charting their path according to the "Help Wanted" signs. Together, they'll chat with store managers about open positions, then sit down and fill out the applications together.

Burpee says helping her clients who have psychosis find work is about more than landing a paying job; it's also about helping them see themselves differently — as independent, career-oriented people, rather than permanent patients dependent on government support programs such as Supplemental Security Income (SSI).

"If you work, you're going to notice a huge improvement in your self-esteem," she tells them. "It has better long term, positive results versus you just sitting around on SSI."

Monet Burpee (right) talks to the manager of a restaurant in Redwood City, CA on one of the job-scouting expeditions she undertakes on behalf of patients receiving a suite of interventions and services for psychosis.

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This is what she told M, and when she was ready, the two of them went to the mall on a job scouting expedition. They filled out the applications together. "Next thing I know, I was being interviewed and I got hired," M says.

She started out as a cashier at a new fast food restaurant and within three months she got promoted to a manager role. Now Burpee is coaching her on how to ask for a raise. "She has a brand new car," Burpee says, beaming with pride. "She's meeting new friends." For M, it was just one step in her long-term recovery plan.

"I want to focus on getting a degree, to get a better career," she says.

A revolutionary idea for treating schizophrenia

The Felton Institute's early psychosis program is one of about 50 in California and 350 in the country. They were started about fifteen years ago with what was then a revolutionary idea.

Back in the 1980 and 90s, doctors didn't really know what to do with schizophrenia, and they didn't have many options. They prescribed doses of antipsychotic medications that were so high, they turned people into zombies. They advised patients to give up on any career ambitions and sign up for disability payments instead. Even today, some doctors still see schizophrenia as a lost cause. "There's a real failure to appreciate how much potential there is to manage the illness and symptoms," says Dr. Daniel Mathalon, a psychiatrist with UCSF's early psychosis program.

Around the turn of the century, a new generation of doctors started thinking: What if we ask patients what they want and actually work with them toward full recovery?

"It's not just about stabilizing you clinically. It's about making sure we don't lose track of your future," says Tara Niendam, a child psychologist who runs the early psychosis clinic at UC Davis. "You should be in college. You should be living on your own."

With other conditions like diabetes or cancer, the sooner people get into care, the better they do. The same is true of psychotic illness. Upwards of 80 studies from early psychosis clinics show that patients see a greater reduction of symptoms, like voices or delusions, and a greater improvement in functioning at school, at work and in their social lives, compared to people who get treatment as usual.

Dr. Tara Neindam at the UC Davis Behavioral Health Center in Sacramento on Feb. 7, 2023. Dr. Niendam is a licensed clinical psychologist with training in assessment and treatment of youth at risk for, or in the early stages of, psychosis.

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There are a few reasons why earlier treatment is more effective, Niendam explains. People respond more quickly to medication given earlier and at a lower dose, so they have fewer side effects that make them want to stop taking them.

In addition, when symptoms are new, patients are more curious about their psychotic experiences, and more willing to question their delusional beliefs. And their families are also more curious, and more willing to stay involved in treatment, she says.

Building circles of ongoing support

This is one reason the early psychosis programs put a lot of emphasis on supporting the families who are supporting the patients.

M's mom found she needed almost as much help as her daughter did after the diagnosis. She blamed herself. She started meeting once a week with Mike Krechevsky, Felton's family specialist. He walked her through what schizophrenia was and wasn't, explained that it was no one's fault, and helped her manage her own feelings about it so that she didn't pass them on to M.

"When you express anxiety to your child, they don't feel as though they have any capability of going out in the world, stumbling, falling, picking themselves up, learning from their mistakes, and moving forward," Krechevsky says. "If you continue to do that, they're never going to recover."

A reverse disparity with insurance coverage

Normally, the separate and unequal health systems in the U.S. favor the wealthy. But in an unusual twist, M and her family were able to get access to such comprehensive, holistic care after her psychotic episode primarily because her mom had lost her job and her commercial insurance plan.

That's because states and the federal government, through block grants and public coverage such as Medicaid, provide most of the funding for early psychosis clinics, an investment that amounts to tens of millions of dollars every year.

Government officials believe that expenditure will save money in the long run, because without sufficient treatment, people with schizophrenia tend to deteriorate to the point that they end up on disability benefits, in a group home, on the street or in jail – all things the government pays for.

But commercial insurance companies, like Anthem or Blue Shield, don't face those risks. They don't have the incentive to cover full-scope psychosis treatment, and most of them don't.

This means low-income families with public insurance like Medicaid, which in California is called Medi-Cal, have more access to this gold standard of care, while working and middle class families covered by private insurance plans usually cannot.

"It is a reverse disparity," said UC Davis' Niendam during testimony before a state senate committee, about the impact of this disparity at the early psychosis clinic she runs in Sacramento.

"I can give the Rolls Royce of care if you walk in and you have Medi-Cal," she said. But "60% of Californians have commercial insurance. That's 60% of kids who can't get care; 60% of kids whose parents call me crying when I tell them they can't access my clinic."

Turning away patients with the wrong coverage

It's the same at the Felton Institute in the Bay Area, according to early psychosis director Adriana Furuzawa. For every one person who has Medi-Cal and is eligible for care at her clinic in Alameda, she says , there are another two with commercial insurance who are turned away. In 2022, they turned about 100 people away.

"It was very difficult to think that behind each number, there is a young person, there is a family, that we're saying no to, when we have the resources right here," Furuzawa says.

So what happens to these kids? Generally, they're on their own to find a psychiatrist and therapist who accepts their insurance. Health plans will pay for these medical services. But they won't cover the other crucial components to the care: the job and education support, the peer specialist, the family coach.

This amounts to discrimination, health advocates argue. If someone has cancer, insurers would never just pay for surgery and radiation, but not chemotherapy.

"It's a package of services," says David Lloyd, former chief of policy at the Kennedy Forum. "So the idea that you can split apart the package of services and only reimburse for little components of it, really destroys the whole evidence base of what the service is."

This almost happened to M. A few months into her treatment, her mom got her job back at the hotel, and the family was again covered by her commercial insurance plan. In most counties in California, this would have meant M got kicked out of the program. Her mom said there would have been no way she could afford to pay for a job coach, a family coach, and a peer specialist on her own.

"I couldn't do it. I would definitely stop all the help," she says, even though that help was critical to keeping M healthy. Maybe she would have turned to Craigslist to find other parents to talk to, she said, or looked up mental health advice on YouTube to pass on to M. "I just hope and pray for the best."

States seek solutions to coverage gaps

In 2022, state lawmakers in California wanted to help families like M's, by forcing insurance companies to cover the full spectrum of early psychosis treatment. Lawmakers in one state, Illinois, enacted a law like this already, while those in Massachusetts and Virginia are working on a similar effort. But the proposal in California, Senate Bill 1337, died under pressure from the insurance lobby.

Historically, insurers have not covered the costs of non-medical services provided by non-licensed staff, like job or family coaches. More importantly, they do not like being cornered into covering specific treatments, said Nick Louizos, a lobbyist with the California Association of Health Plans, a trade group that represents companies like Anthem, Blue Shield and Kaiser.

"Science evolves. Research evolves. There could be evidence-based techniques that are better in the future," Louizos said during testimony at a state senate health committee hearing.

While there are scores of studies that show the treatment works in the short-term — people are more likely to stay in school, in jobs, in treatment, and out of the hospital — the treatment hasn't been around long enough to know how long the positive effects last.

"There is a lack of evidence of this model's long-term effectiveness," Louizos said.

Perverse incentives to drop private coverage

The private insurance restrictions create a perverse incentive for middle-income families who need help now. Some parents are so desperate to give their kids the best care, they actually drop them from their health plan and enroll them in Medi-Cal so they can access county-funded clinics like Felton.

Some counties, including Sacramento and San Mateo, have taken an even bolder step. Health officials there determined that denying young people the full suite of care is unethical, so they decided to use county taxpayer dollars to pay for any services that private insurers refuse to cover.

In the end, this extra support at the county level is what allowed M to stay in the Felton program.

But all of these workarounds are problematic, according to Lloyd. For-profit insurance companies are essentially making more profits by allowing the public to pay their bills.

"That's not an appropriate role for taxpayers to be picking up that burden," he says. In addition, the lack of funding from private insurance reimbursement is stifling the growth that's needed in these programs to hire more employees and provide care for all the young patients who need it.

In California, an alternate pathway to full coverage?

In California, expanded coverage and access could be arriving soon, via a different legal mechanism.

A novel 2021 California law was designed to expand the kinds of mental health care insurers are required to cover. Under this law, SB 855, health plans must make mental health coverage decisions based on expert-recognized guidelines for treatment, rather than their own internal, often arbitrary or cost-driven, criteria.

Multiple agencies, including the National Institute of Mental Health, the Centers for Medicare and Medicaid Services and the American Psychiatric Association, all recommend full-scope early psychosis care for treatment of a first psychotic episode.

Since this story was first published last spring on KQED.org, California's largest state health regulator, the Department of Managed Health Care, finalized guidance that explicitly requires insurers to cover full-scope early psychosis care, and is incorporating that guidance into the official rules that will be used to enforce SB 855. The final version of the regulations is expected to take effect in spring of 2024.

M and her family haven't had time to follow all these legislative battles and policy changes. All they know is that the full-scope early psychosis care has been life changing.

M has struggled recently with some of symptoms at her new fast food job. The difference is that now she knows what's happening. She has new skills to help quiet the voices. She knows her mom will understand and support her. And she knows there are half a dozen providers at Felton who will pick up if she calls for help.

When her mom thinks about the generosity of those providers, or the luck of landing in a county that stepped up and paid for all of M's care, she thinks about her own father. He was a doctor in the Philippines, and none of his patients had insurance. If they didn't have money, he treated them anyway. "I remember people paying him with chicken and rice," she says.

She thinks, maybe all the help M got was because of him. Maybe it was her dad's karma paying off.

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

Dan Shimell, an attorney and a new face in local politics, is Santa Ana’s next mayor after a shocking win against incumbent Valerie Amezcua. His win has become one of the most surprising upsets in Orange County’s general election and marks a shift for a city that previously elected its first Latina mayor.

Amezcua congratulated Shimell on social media late Monday night after the last round of election results nearly doubled Shimell’s lead. As of Tuesday night, Shimell held a 5-point lead over Amezcua. Amezcua did not respond to LAist’s requests for comment.

“It has been the honor of my life to serve the people of Santa Ana,” Amezcua said in a post. “Together, we have accomplished great things. We invested in our neighborhoods, expanded opportunity for families, and strengthened the services that make Santa Ana home. Our work was never about one person. It was about all of us moving this community forward.”

Aside from Shimell, progressives Sandra de Anda and Isuri S. Ramos are also projected to win City Council seats, deepening the Santa Ana City Council’s progressive bench.

A flashpoint in Amezcua’s re-election campaign was during the U.S. Immigration and Customs Enforcement raids that rattled much of Southern California, including Santa Ana, Orange County’s only sanctuary city. The raids sparked protests that drew a heavy law enforcement response from Santa Ana police, including rubber bullets and tear gas.

In Amezcua’s first public response, she accused protesters of inciting chaos and violence. She later walked back her comments in a city statement, saying most protesters were demonstrating peacefully and that she did not support the raids.

Shimell told LAist he thinks Santa Ana voters, especially young and first-time voters, went to the polls to vote for those who can't.

“Those who have been or might in the future be impacted by immigration policy and enforcement,” Shimell added. “Taking a bold stance on immigration and police accountability seemed to resonate with voters I spoke with, and stood in stark contrast to the [police]-backed candidates who remained largely silent on those issues.”

What does this say about Santa Ana politics? 

Orange County Supervisor Vicente Sarmiento served as mayor of the city from 2020 to 2022, and his current district includes Santa Ana. Sarmiento told LAist that the results were surprising but reflected the change voters want to see in their elected officials.

“I think the underlying message is that money and establishment conventional politics no longer is the formula to success in a campaign in the city,” Sarmiento said. “It's really the influence of people and voters over money. That's really the theme here.”

Santa Ana City Councilmember Thai Viet Phan told LAist that the race results were somewhat surprising — but spoke to a larger trend.

“[In] the election results throughout the country … you saw a very leftward shift, with not just candidates but also just how voters voted,” Phan said. “I think that was reflected here in Santa Ana on the council.”

Amezcua outspent Shimell — by a lot

Shimell raised about $28,500 in his campaign for mayor. Amezcua raised more than $75,000 and received more than $200,000 in outside support — more than half of that came from the Santa Ana Police Officers Association.

Mike Moodian, a public policy professor at Chapman University, told LAist that in many ways, the races capture the zeitgeist of Santa Ana.

“Here we saw that there was a police union-backed group, and there was a resistance to that,” Moodian said. “People might have seen the incumbent mayor as part of a police union-backed establishment."

He explained that voters may have looked at Shimell as a fresh face who can represent more people and that the city is experiencing a deeper progressive shift.

“I find the residents of Santa Ana tend to be much more involved and engaged in local politics than most other cities in Orange County. So you also have a well-informed, engaged citizenry that showed up, and the voices were heard in Santa Ana,” Moodian said.

Moodian said Amezcua may have lost support from some voters because they were unsatisfied with her response to immigration enforcement.

What’s next?

Ballots are still being counted. The OC Registrar of Voters posts updates every day, except Sundays, at 5 p.m. Election results will be certified by Dec. 3. You can find updates on key measures and other races here.

For seven years, Nazmul Chaudhry has been trying to get the city of Los Angeles to fix a broken sidewalk in front of his store.

Chaudhry owns Deshi Food, a restaurant and grocery store in Little Bangladesh. Before I could even begin our interview, he led me to the front of his store to show me the sidewalk that pedestrians sidestep and electric scooter riders slow down around.

He said he’s tried to get the attention of city officials, but nothing has been done.

The broken sidewalk in front of Nazmul Chaudhry's shop in Little Bangladesh.

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He’s hoping that will soon change. He said then-candidate Nithya Raman spent time in the historic enclave just north of Koreatown this fall, talking with community members about their problems. For the first time since he moved to the United States in 1989, Chaudhry is excited about a mayoral election.

“Everybody's happy because we've never seen anyone [come] like that directly to us,” Chaudhry said.

Mayor-elect Raman is of Indian descent and an immigrant. When she takes office, she will be the first South Asian mayor of Los Angeles. Chaudhry is proud of that distinction. But what means more to him is that Raman spent time walking the streets of Little Bangladesh, visiting businesses and speaking to community members about their concerns. Chaudhry said that, because of that, he asked all his customers and family members to vote for Raman. At dinner parties, Chaudhry said, Bengalis would share how they were excited to vote for Raman in this election.

Nazmul Chaudhry and one of his customers, Mohamed Hassen. They both voted for Nithya Raman for mayor.

In the Little Bangladesh area, vote returns to date show Raman with a 2-to-1 margin over Mayor Karen Bass.

 "Hopefully she's gonna take care of the city," Chaudhry said.

His business has been hit hard after federal immigration raids ramped up in Southern California. People are afraid to leave their homes for fear of being taken by U.S. Immigration and Customs Enforcement. And for those who do come to his store, he said, they are met with increased prices because of tariffs imposed by President Donald Trump's administration on imported goods.

Nazmul Chaudry offers a lunch buffet at his restaurant but he has seen a drop in foot traffic after ICE raids ramped up.

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"Everybody's suffering actually these days," Chaudhry said. “If you see, Nov. 3 is a huge change because people [are] fed up."

Chaudhry also said city services don’t do a good job keeping the streets clean. So he takes it upon himself to pick up trash in front of his shop.

A few weeks before Election Day, Raman posted a social media video from Little Bangladesh addressing the trash along the street.

His relatives in New York told Chaudhry that New York City Mayor Zohran Mamdani, also of Indian descent, has “changed the whole city.” He’s hoping for some of that change in Los Angeles when Raman takes office in December.

Shift away from identity politics

While Raman’s Indian background was a feature of her campaign, it was “not the central thesis,” said Sara Sadhwani,  an associate professor of politics at Pomona College and a senior researcher with AAPI Data.

In 2020, when Kamala Harris, also of Indian descent, was running for vice president, Sadhwani said, she conducted research on Indian Americans who wanted to see more representation in politics. In 2024, some of them turned away from Harris.

“When the economy is bad, identity slips away as the top issue on someone's mind,” she said.

Identity politics, Sadhwani said, was important in 2008 when the nation elected the first Black president, Barack Obama.

Los Angeles mayor-elect Nithya Raman poses for a photograph with family members after casting her vote on Election Day during the midterm elections at the Silverlake Community Church.

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“ We're ushering in a new political generation of millennials and Gen Z; diversity is just expected at this point amongst a vast majority of Americans,” she said, highlighting how at the last census more people identified as multiracial.

Nationally too, Sadhwani said, thec ountry is seeing a shift. South Asians have gone from “model minority” to “governing minority.”

”The old script was that for Indian Americans, for South Asians, that being that quiet professional is what success meant,” she said. “When we look at Raman and also Mamdani, they're fighting for executive power in very visible, very messy city politics, and they won not by following the rules, but they won by challenging the status quo.”

South Asians as a political force

That idea resonates with Faizah Malik, managing attorney for housing justice at Public Counsel and a former L.A. City Council candidate.

“When we were growing up, our parents said, ‘Just keep your head down, go to school, get educated, make a nice life for your family, and that's it,’” she said. “Politics was not really part of the conversation, but I think what we're seeing is that we can run for office, we can win by being our full selves.”

This is an exciting time, she said, for “South Asian political empowerment,” with Raman set to join Mamdani in leading the country’s two largest cities.

Malik said that, as a housing advocate, she cares about Raman’s fight “to build more housing around the city that people can afford, her fight to keep renters in their homes, to prevent homelessness, her fight to try and really solve our homelessness crisis but also be efficient with our public dollars.”

Nikita Chaudhry, an actor and political organizer, wants to see Raman revitalize L.A.’s film industry, “to call the city the home of Hollywood again.”

“Having that kind of representation and knowing that it exists is really exciting because I think and hope it will activate South Asian Americans of all ages to get more involved in their communities,” Chaudhry said.

Raman's and Mamdani’s victories were years in the making, Chaudhry said: from organizing in their communities to holding other elected positions to engaging voters who are otherwise ignored by elected officials. And she hopes that it will inspire other South Asians to become more involved in their communities.

“If you're feeling activated, if you're feeling excited, that's great," she said. "Take that energy and the time and the skills and the specificity of what fires you up towards your local organization, towards your neighborhood, towards your community.”

As the race to represent L.A.’s Council District 9 remains too close to call, candidate Estuardo Mazariegos’ campaign has accused the campaign of Jose Ugarte, the front-runner, of potential ballot tampering.

The Mazariegos campaign made the accusations Monday, saying it had filed a complaint with the Los Angeles County Registrar-Recorder/County Clerk. In a press release, the campaign alleged that representatives for the Ugarte campaign had collected voters’ ballots to drop off without signing the appropriate line identifying the individual who returned the ballot.

In one case, Mazariegos’ team accused Ugarte campaigners of filling out a ballot on a voter’s behalf without her knowledge of who she was voting for.

“Taking people’s ballots, filling them out, and not following legal voter assistance guidelines in a district that has faced so much disenfranchisement is disgusting,” Mazariegos said in a statement.

Mike Sanchez, a spokesperson for the L.A. County Registrar-Recorder/County Clerk, said his office had forwarded the news release to the district attorney for review. He also pointed to the California Elections Code, which says that a “ballot shall not be disqualified solely because the person authorized to return it did not provide on the identification envelope their name or signature.”

Under California law, a voter can authorize another person to return their mail-in ballot — an approach also called ballot harvesting.

Justin Levitt, a  professor of constitutional law at Loyola Marymount University, told AirTalk Tuesday that there is no legal limit on the number of ballots an individual can turn in on others’ behalf, so long as they aren’t being compensated per ballot returned.

“Even if there were some sort of administrative wrongdoing, as long as there's no indication of fraud with the ballot itself, those ballots will all be counted,” he said.

Levitt said, however, that signing a ballot and then handing it to someone else to fill out would be illegal.

“ To the extent that there are allegations now that the DA may investigate, I suspect that's what they'll be focusing on,” Levitt continued.

The Mazariegos campaign also sent a collection of photos to the press, including one of a campaigner, USC student Amir King, returning a stack of ballots at a ballot drop box.

The Mazariegos campaign alleged that representatives for the Ugarte campaign had collected voters’ ballots to drop off without signing the appropriate line identifying the individual who returned the ballot.

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Ugarte’s campaign responded to the accusations by pointing to a post by King on Instagram in which he accused the Mazariegos campaign of bullying him and making false claims about him.

“Why is he attacking me? For participating in our democracy, as is my right under California state law and for helping others participate in democracy, as is their right under California state law,” King said in the post.

As of Tuesday morning, just under 300 ballots separate Ugarte and Mazariegos, with 44,000 ballots left to count in L.A. County. It’s not clear how many ballots in Council District 9 are left to count.