California voters will decide on Newsom’s mental health overhaul. How did we get here?

Fallout from our state’s long history of breaking promises to people with serious mental illness is everywhere.

It can be found under our overpasses and in our tent encampments, but also inside our jails and prisons, our emergency rooms, our schools, our homes.

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It flashes across our public opinion polls, which repeatedly list mental health as a top concern.

Increasingly, it makes its way into our political discourse. Referencing “our broken system,” Gov. Gavin Newsom in recent years has rolled out mental health policies with dizzying speed.

Now he’s promoting Proposition 1, a two-pronged March ballot measure that would fund a $6.4 billion bond for treatment beds and permanent supportive housing, while also requiring counties to spend more of their existing mental health funds on people who are chronically homeless. 

The measure makes promises of its own. 

“These reforms, and this new investment in behavioral health housing, will help California make good on promises made decades ago,” Newsom has said.

What are the promises that California has made to people with mental illness over the years? And why are so many people still suffering?

Here’s a brief timeline of mental health policies in our state—of promises made and promises broken—during the past 75 years.

1950s & 1960s: An era of institutionalization

In the 1950s, it is relatively easy to force people into state mental hospitals, many of which have horrific conditions. The number of patients peaks in the late-1950s, at approximately 37,000. During that time, the state starts shifting control over mental health services to counties, embarking on the process of deinstitutionalization. This process accelerates in the late 1960s with the passage of the landmark Lanterman-Petris-Short Act, a law designed to protect the civil rights of people with mental illnesses.

1954: The federal Food & Drug Administration approves Chlorpromazine (Thorazine), the first antipsychotic drug, to treat people with serious mental illnesses.

1957: The California Legislature increases funding for community mental health under the Short-Doyle Act, aiming to treat more people in their communities instead of in state hospitals.

1963: President John Fitzgerald Kennedy signs the Community Mental Health Act, promising federal leadership to build and staff a network of community mental health centers. Less than a month later, he is assassinated. Many of the clinics are never built.

1965: Congress creates Medicare and Medicaid, allowing people with mental illnesses to receive treatment in their communities.

1967: Then-Gov. Ronald Reagan signs the Lanterman-Petris-Short law limiting involuntary detention of all but the most gravely disabled people with mental illness and providing them with legal protections.

1970s & 1980s: California tax revolt leads to austerity

As state mental hospitals close in the 1970s, many people with serious mental illnesses are moved into for-profit nursing homes and board and care homes. Their numbers on the streets and inside jails and prisons begin to rise. The 1980s sees significant funding cuts for mental health services at both the state and federal levels.

1978: The Community Residential Treatment Systems Act seeks to create unlocked, noninstitutional alternatives for people with mental illness throughout California.

The same year, voters pass Proposition 13, capping property taxes and reducing the amount of money available to counties for a variety of services, including mental health.

Click here to read the full article in CalMatters

‘You have a crisis out there’: Gavin Newsom scolds counties over delays in mental health law

One of the counties that is operating a CARE Court, Riverside, is taking more time to adopt the conservatorship law. Newsom singled it out at his press conference. 

“Riverside County (is) doing great work on CARE Court, but decided not to move forward with the implementation of conservatorship,” Newsom said. 

Riverside County officials said they’re not ready to carry out changes to the conservatorship law, which carries “significant responsibilities.” The county’s behavioral health department, hospitals and law enforcement need time to expand treatment facilities, increase housing capacity, develop new protocols and train staff, Dr. Matthew Chang, behavioral health director of Riverside University Health System, said to the Riverside County Board of Supervisors. 

“Setting an implementation date in 2026 would signal our commitment to getting it right for our community,” Chang said during board remarks.

Mayors back Newsom’s timeline

Several California mayors, by contrast, are urging counties to move faster. Mayors often bear the brunt of residents’ complaints about homelessness, but they tend to have little influence over social services and mental health spending. 

San Diego Mayor Todd Gloria, who supported a majority of Newsom’s mental health reforms, urged his county’s board of supervisors to implement the conservatorship expansion immediately.

“While the law allows for counties to delay implementation until 2026, our county is experiencing an unacceptable behavioral health crisis – one all of us see clearly every day in our communities. Putting implementation off will cost people their lives,” Gloria and other San Diego County mayors wrote in a letter to the board this month.

Nora Vargas, chair of the board of supervisors, initially proposed delaying implementation to 2025 after hospital and behavioral health leaders argued more people would cycle in and out of the emergency room without proper support. 

“San Diego County will implement (the conservatorship law) in a way that is methodical and equitable because these are real people and real families seeking care,” Vargas said in a statement to CalMatters. 

Tim McClain, a spokesperson for San Diego County Health and Human Services Agency, said the county is moving as quickly as possible despite receiving no support from the state. 

The law “comes with no new resources for hospitals, substance use disorder treatment providers, or county run public conservator offices. It doesn’t establish clinical assessment criteria that will incline clinicians to extend holds. And it doesn’t do anything to create the operational tools that will actually get people with substance use disorder from (emergency departments) into ongoing addiction treatment,” McClain said in a statement to CalMatters.

Demand on mental health system

Among the concerns raised by counties is a dramatic influx in the number of people needing treatment.

In Kern and Santa Barbara counties, behavioral health officials have said they expect the number of people who would qualify for involuntary treatment to increase tenfold, The Bakersfield Californian and Santa Barbara Independent have reported. 

Behavioral health officials in Stanislaus County told their board of supervisors that because the expanded definition of “gravely disabled” will now include people with drug use disorders, the number of conservatees will likely go up. They say they need additional staff and coordination to handle a larger population. There are also very few treatment settings for people with severe substance use disorders in the county, health officials said. 

The Stanislaus County Board of Supervisors agreed to push back implementation, but supervisors said they would like to enact the law sometime before 2026.

In neighboring San Joaquin County, supervisors this week also voted to delay the law’s implementation.

“We need the state to provide us with guidance on how we can best apply this law to help the vulnerable and protect people’s civil rights while ensuring their treatment,” Supervisor Robert Rickman said in a press release.

If any year is looked back on as pivotal in California’s fight to curb mental illness, homelessness and drug-related deaths, 2023 could be the one. Gov. Gavin Newsom pushed major — and at times controversial — reforms of the state’s mental and behavioral health systems through the Legislature, but a mere two months after signing the laws, Newsom accused counties of moving too slowly to adopt them.

Newsom on Friday at a press conference took local governments to task, publicly pressuring them to take action on the state’s new conservatorship law.

“The state has done its job. It’s time for the counties to do their job,” Newsom said.

In October, lawmakers significantly loosened long-standing rules limiting who can be placed in involuntary treatment. The change to the state’s conservatorship rules allows people who can’t take care of their own medical needs or personal safety to be deemed “gravely disabled” and placed in treatment facilities without consent. This includes people struggling with addiction. 

But the vast majority of counties have opted to delay implementing the conservatorship expansion, putting them at odds with the governor’s timeline. They play a critical role in the law because they administer the state’s social services and mental health programs. 

County leaders say they need more guidance and resources. They argue they lack the staff and funding to move this new policy forward. The law goes into effect in 2024, but allows counties to defer implementation until 2026.

Fifty-six counties out of the state’s 58 are requesting permission to delay implementing the law, Tony Vartan, Stanislaus County’s Behavioral Health Director, told his Board of Supervisors this week. 

Only San Luis Obispo and San Francisco counties plan on beginning implementation next month, Vartan said.

Newsom said during Friday’s press call that the “lack of urgency” at the local level was disappointing.

“You have a crisis out there. There’s a crisis on the streets and people are talking about delaying the conservatorship efforts till 2026. We can’t afford to wait,” he said.

Michelle Doty Cabrera, executive director of the County Behavioral Health Directors Association of California, said in a statement behavioral health departments are “already stretched” thin and need time to coordinate such a complex change. In the past two years, they’ve been hit by increased demand for services, widespread provider shortages, and a series of new state mandates.

“County boards of supervisors across California have heard clearly from hospitals, law enforcement officials, and county behavioral health professionals that infrastructure capacity, staffing and training must be in place to make the law successful,” Cabrera said.

California counties singled out

The change comes on the heels of another major Newsom mental health initiative. CARE Court, which passed last year and began rolling out in October, allows people with untreated mental illness to be placed in court-mandated treatment programs and housing

So far, eight counties are operating a CARE court. Now, most of those early adopters have chosen to delay the conservatorship expansion.

One of the counties that is operating a CARE Court, Riverside, is taking more time to adopt the conservatorship law. Newsom singled it out at his press conference. 

“Riverside County (is) doing great work on CARE Court, but decided not to move forward with the implementation of conservatorship,” Newsom said. 

Riverside County officials said they’re not ready to carry out changes to the conservatorship law, which carries “significant responsibilities.” The county’s behavioral health department, hospitals and law enforcement need time to expand treatment facilities, increase housing capacity, develop new protocols and train staff, Dr. Matthew Chang, behavioral health director of Riverside University Health System, said to the Riverside County Board of Supervisors. 

“Setting an implementation date in 2026 would signal our commitment to getting it right for our community,” Chang said during board remarks.

Mayors back Newsom’s timeline

Several California mayors, by contrast, are urging counties to move faster. Mayors often bear the brunt of residents’ complaints about homelessness, but they tend to have little influence over social services and mental health spending. 

San Diego Mayor Todd Gloria, who supported a majority of Newsom’s mental health reforms, urged his county’s board of supervisors to implement the conservatorship expansion immediately.

“While the law allows for counties to delay implementation until 2026, our county is experiencing an unacceptable behavioral health crisis – one all of us see clearly every day in our communities. Putting implementation off will cost people their lives,” Gloria and other San Diego County mayors wrote in a letter to the board this month.

Nora Vargas, chair of the board of supervisors, initially proposed delaying implementation to 2025 after hospital and behavioral health leaders argued more people would cycle in and out of the emergency room without proper support. 

“San Diego County will implement (the conservatorship law) in a way that is methodical and equitable because these are real people and real families seeking care,” Vargas said in a statement to CalMatters. 

Tim McClain, a spokesperson for San Diego County Health and Human Services Agency, said the county is moving as quickly as possible despite receiving no support from the state. 

The law “comes with no new resources for hospitals, substance use disorder treatment providers, or county run public conservator offices. It doesn’t establish clinical assessment criteria that will incline clinicians to extend holds. And it doesn’t do anything to create the operational tools that will actually get people with substance use disorder from (emergency departments) into ongoing addiction treatment,” McClain said in a statement to CalMatters.

Demand on mental health system

Among the concerns raised by counties is a dramatic influx in the number of people needing treatment.

In Kern and Santa Barbara counties, behavioral health officials have said they expect the number of people who would qualify for involuntary treatment to increase tenfold, The Bakersfield Californian and Santa Barbara Independent have reported. 

Behavioral health officials in Stanislaus County told their board of supervisors that because the expanded definition of “gravely disabled” will now include people with drug use disorders, the number of conservatees will likely go up. They say they need additional staff and coordination to handle a larger population. There are also very few treatment settings for people with severe substance use disorders in the county, health officials said. 

The Stanislaus County Board of Supervisors agreed to push back implementation, but supervisors said they would like to enact the law sometime before 2026.

In neighboring San Joaquin County, supervisors this week also voted to delay the law’s implementation.

“We need the state to provide us with guidance on how we can best apply this law to help the vulnerable and protect people’s civil rights while ensuring their treatment,” Supervisor Robert Rickman said in a press release.

Click here to read the full article in CalMatters

Gavin Newsom’s Mental Health Plan Could Strip More Than $700 Million From Services, Report Says

A major proposal from Gov. Gavin Newsom to overhaul the state’s behavioral and mental health system is likely to take nearly $720 million away from services provided by county governments annually, according to a new analysis from the Legislative Analyst’s Office.

Although that money would be reallocated within the system, in part to house homeless individuals with severe mental illness and addiction disorders, the report authors note that Newsom and key legislators supporting the proposal have neither provided a complete justification for the changes nor have they published an analysis on how the changes may “negatively impact current services.”

“Consequently, as the Legislature considers the proposal, we recommend asking the administration certain questions to assess whether the proposal is warranted,” the report states.

Newsom wants the Legislature to put his proposal before voters next year in tandem with a $4.68 billion bond measure to add psychiatric treatment beds. It would change how the state allocates money under the Mental Health Services Act, which levies a 1% tax on income above $1 million to fund behavioral health services. 

“What’s more upsetting is watching people continue to suffer on the streets with ineffective interventions and inability to access much needed treatment.”BRANDON RICHARDS, GOV. NEWSOM’S DEPUTY COMMUNICATIONS DIRECTOR

Homelessness has become one of the most high-profile challenges plaguing California, increasing 32% in the past four years. Newsom, who promised to reduce homelessness, announced his intent during his State of the State tour to divert nearly one-third of the state’s Mental Health Services Act money to help address homelessness.

Since that time, local behavioral health providers and county officials have criticized the proposal because of its potential to cut services and pit mental health programs against homeless services. The state has spent more than $20 billion on housing and homelessness since 2018

Supporters, meanwhile, say reprioritizing how the money is spent is long overdue in light of the growing needs of the state’s homeless population as well as the addition of new funding sources for mental health programs.

In a statement, Newsom’s Deputy Communications Director Brandon Richards said “upsetting the status quo” was necessary in light of California’s changing health care needs.

Mental health needs among California homeless

A recent study from UC San Francisco found that two-thirds of homeless individuals experience mental health conditions, although income loss is the driving force behind the state’s homelessness crisis. 

“What’s more upsetting is watching people continue to suffer on the streets with ineffective interventions and inability to access much needed treatment,” Richards said. “A California behavioral health system of care that is more focused, more transparent, and more accountable for results is what all Californians deserve and what this historic reform aims to achieve.”

Roughly one-third of the county mental health infrastructure in the state is supported by the Mental Health Services Act, which was approved by voters in 2004 as a ballot initiative. Substantial changes to the act, like the ones Newsom proposed, require voter approval. Last year the tax generated about $3.8 billion.

Critics of Newsom’s proposal say the new analysis bolsters their argument that the changes will result in significant cuts to current programs, particularly those that support children

Newsom’s office has so far “danced around” how much money would be cut, said Adrienne Shilton, a lobbyist for the California Alliance of Children and Family Services, which represents behavioral health providers in every county. The report is the first to quantify how the proposal would impact programs statewide.

“We’re seeing in real dollars what the impact would be,” Shilton said.

The analysis estimates spending on current programs would be reduced from $1.34 billion to $621 million under the plan.

Housing money in Gavin Newsom’s plan

The report identified a number of key changes and unanswered questions for the Legislature to consider in Newsom’s plan:

  • Reduced flexibility: Counties would have less flexibility to determine how money is spent. Based on current expenditures, counties would be required to increase spending on housing by $493 million and on “full-service partnerships” by $121 million. “Full-service partnerships” include intensive wraparound services like case management, housing and employment support as well as clinical care. 
  • Program cuts likely: In order to meet spending targets and caps, counties would likely need to reduce spending on current programs including “outpatient services, crisis response, prevention services, and outreach.”
  • Less independent oversight: The proposed restructuring moves much of the program implementation and oversight authority to the Department of Health Care Services. The change “significantly limits” the independent oversight of the current Mental Health Services Oversight and Accountability Commission.

Sacramento Mayor Darrell Steinberg, who helped author the original law and who has been a key supporter of the changes, said the law was always meant to prioritize “the plight of people living with serious mental illness on our streets.”

“It’s appropriate, in fact, it’s necessary to set priority status,” Steinberg said.

Steinberg and Newsom’s office also contend that the state has invested heavily in the mental health safety net in other ways, including changes to the Medi-Cal system and a $4.4 billion one-time infusion into the Children and Youth Behavioral Health Initiative

“It’s no longer a funding source that stands alone,” Steinberg said. “(Now), the opportunity is to weave all these pieces together so that everyone has access to care, and nobody is left out or left behind.”

Still, advocates say it is premature to assume those investments have had a positive impact and that many have not yet been implemented. In an opposition letter, Lishaun Francis, senior director for behavioral health at Children Now said the state “has yet to demonstrate that it has delivered” on its promises and that the proposal deprioritizes children and youth.

“The opportunity is to weave all these pieces together so that everyone has access to care, and nobody is left out or left behind.”DARRELL STEINBERG, MAYOR OF SACRAMENTO

Advocates also say those funding sources, particularly Medi-Cal, won’t reimburse for the non-clinical programs like classroom interventions and family resource centers that have historically been supported by the Mental Health Services Act. Medi-Cal is the state’s health insurance program for extremely low-income Californians.

Click here to read the full article at CalMatters