Changes in mental health care system spur new optimism

Massive changes in how mental health care is delivered to Californians – including abolishing or restructuring the two state departments responsible for mental health and substance-abuse programs – are being closely watched by care providers and advocacy groups.

They say they are “cautiously optimistic” that Gov. Brown’s plan will result in a coordinated, community-based system of care for the thousands of people who historically have faced a dizzying patchwork of care, or no care at all.

But advocates emphasize that mental-health care must have a prominent position in the state bureaucracy.

“We need somewhere to go to at a very high senior policy level,” said Mark Gale, chairman of the public policy committee for the California arm of the National Alliance on Mental Illness and the father of a mentally ill son. “We need someone at the highest level who understands core mental health policy, law and regulations, someone who has lived it. If we don’t get this right, the system will become extremely dysfunctional. If we get it right, there is great opportunity.”

Financed in part through a one-year appropriation of $861 million in the 2011-12 budget from the so-called “millionaire’s tax” approved by voters in 2004 as Proposition 63 to fund new mental health programs, the reorganization aims for a coordinated approach to mental health – and a major shift from the state to the counties for funding and managing mental-health programs, with state oversight.  

Some services are being moved to the huge state Department of Health Care Services. There is talk of two new departments – one under the rubric of “Behavioral Health” or “Mental Health and Substance Abuse,” and another for “Institutions” or “State Hospitals” to administer the remaining state hospitals, which primarily house the criminally insane.  A recent spate of assaults, including the strangulation death of a psychiatric technician at Napa State Hospital last October, has prompted a series of state and federal crackdowns at those facilities, which currently house nearly 6,000 patients.     

A major concern is abolishing the Department of Mental Health.

“There is tremendous fear in the mental health community about eliminating the Department of Mental Health,” said Rusty Selix, longtime executive director of the Mental Health Association in California. Selix is the co-author, with state Senate President Pro Tempore Darrell Steinberg, D-Sacramento, of the landmark Mental Health Services Act, passed by voters in 2004 as Proposition 63.  

“Where are we left if the next administration doesn’t have the same level of interest?” Selix added.    

Representatives of advocacy and professional groups are vocal participants in public hearings held throughout the state in August and September by the state Health and Human Services Agency and the soon-to-be defunct Department of Mental Health. The hearings solicit comments for the complex reorganization plan taking shape at the state and local level.

 “There are a lot of pieces to this puzzle, and we need to look at it as a whole – courts, prisons, police, state hospitals, community programs – and re-engineer a system that works better,” said Randall Hagar, government affairs director for the California Psychiatric Association, who has followed mental health issues for decades and is the father of a schizophrenic son. He says the Brown administration’s reorganization proposals come at a critical juncture for both providers and families. “Some of the tools are there already, but we have a system that has evolved piecemeal for nearly five decades.”

Rose King, a legislative and state policy expert on mental-health issues (who is the widow, mother and grandmother of mentally ill family members), has regularly attended the ongoing “stakeholder” meetings and expresses increasing concern that the vague outlines of a new system still fail to address historic discrimination against the mentally ill, despite state and federal laws requiring parity in treatment for mental as well as “physical” health.

But she says the reorganization “has great potential” and “creates an opportunity for the integration of mental illness and substance abuse disorders” – and to close the disparities in treatment of mental  and physical health care.  

Pat Ryan, executive director of the California Mental Health Directors Association, which represents county mental health directors, said the goal of the reorganization “is to get people help sooner rather than later, to avoid both incarceration and institutionalization. If you starve the system and don’t have money specifically intended for prevention and early intervention, you’re never going to get there, because you’re always going to be dealing with crises.” Like other advocates and providers, Ryan said “leadership is critical” in any new system – in which the counties will play an increasingly larger role under the Brown administration proposals and federal health care reform.

“The idea is to get the money flowing directly to counties with fewer strings and less bureaucracy,” said  Farah McDaid Ting, senior legislative analyst for the California State Association of Counties.  “It’s an opportunity for counties to take an integrated approach and offer a continuum of services. We haven’t had that opportunity before.”

Central to the reorganization are lessons learned from the tortuous implementation of Proposition 63, which levied a 1 percent tax on millionaires and provided $900 million to $1.5 billion annually in additional revenue for local mental health programs.

Hailed as the first significant infusion of state funding for mental health since the closures of decrepit, understaffed and overcrowded state mental hospitals nearly four decades earlier – dumping huge numbers of mentally ill people on communities ill-equipped to handle them – Prop. 63 became both an important harbinger of change and a bureaucratic nightmare.  
Critics of its implementation – including some of those who helped write the law – say the process was plagued by red tape, glacially slow state Medi-Cal payments to counties, high consultant fees, accusations of cronyism,  and only a trickle of funds for actual programs.  

While success stories emerged from communities where homeless mentally ill for the first time found coordinated housing and treatment with Prop. 63 funding, thousands more received little or no treatment, continuing on a tragic downward spiral of homelessness, institutionalization and incarceration, worsened by the severe economic downturn and draconian budget cuts.

The state required counties to jump through an array of bureaucratic hoops and “pre-approvals,” infuriating local officials.  At the same time, there were broad state and local cuts to social programs, with some Prop. 63 funds used in recent years to help balance the precarious California budget.

 “The planning process went on and on,” says former Yolo County Supervisor and state Assemblywoman Helen Thomson, D-Davis, who chaired the Joint Legislative Committee on Mental Health and the Assembly Health Committee and is a former psychiatric nurse married to a psychiatrist.

“Every county hired a different kind of consultant. A lot of money was going into the Prop. 63 fund, and it was bureaucratized.” While some new Prop.-63-funded programs provided services, she said, “clinics were closing, beds eliminated.” In
tended to supplement existing services and create new programs, Prop. 63 funds were used by cash-strapped counties to finance dwindling mental-health services.

Hagar says the language of the law included “something for everybody, to get everybody on board,” in order to ensure its passage. “Unfortunately, it was so diffuse that we had a lot of exemplary projects developed, doing a wide range of things – suicide prevention, school-based services – while heavy-duty services, core services for those who were homeless or not ‘engaged’ in the system,  did not receive the same level of support.”

Steinberg remains one of its most passionate proponents, and is clearly stung by what some say is the scapegoating of a landmark law.

“You can’t blame [Prop. 63] for the problems of a mental health system that has been decades in the making,” he said.  Quick to criticize the cumbersome implementation process, he is hopeful the current reorganization will address flaws in the process. “The process has been faulty, and it has gone too slowly at times. It’s been way too slow off the mark in reporting data.” Still, he added that despite setbacks, the 2004 law “remains a monumental accomplishment,” and, when fully implemented, will help provide coordinated care and keep the mentally ill out of jails and prisons.  

“The fact is that we’re living through the worst recession in 50 years, and we’ve cut budgets in ways I abhor,” he added. “Prop. 63 was never intended to be the solution for all of the system’s problems. It was intended to provide comprehensive care for people with severe mental illness, with the main goal of keeping people out of the system. ”

The law included specific requirements that funds be used only for “new” services (not existing programs), and not for jails or prisons. The complex approval process that evolved, administered by the state Department of Mental Health, will likely be scrapped by 2012-13, along with the department – “reorganized” or “redirected” in state budgetary parlance – as will the state Department of Alcohol and Drug Abuse.

While state administrators are deep in a widely publicized “Public Safety Realignment,” less has been said publicly about the administration’s lower-key efforts to coordinate mental-health and substance-abuse programs with the state’s vast and costly correctional system, which faces massive court-ordered population reductions and mandated improvements to all aspects of prison health care.  

Since many prisoners are also mentally ill and vast numbers are serving time for drug-related crimes, advocates say coordination of mental-health and substance-abuse services at the local level is critical to any reorganization plan, and could help avert much more expensive, sometimes deadly, arrests and incarceration.

Local officials express relief that some of the bureaucratic hoops, especially the much-maligned “pre-approval” process for Prop. 63 funding, will be eliminated, and that Medi-Cal reimbursement backlogs – which often stacked up for months, leaving counties holding the bag – will be reined in.

Newly appointed Health and Human Services Agency Undersecretary David Maxwell-Jolly, the former state Health Care Services Department director who is overseeing the reorganization with Agency Secretary Diana Dooley, said technological improvements have dramatically reduced the paperwork blizzard and Medi-Cal backlogs. He noted that state officials were “less responsive and perhaps less efficient than we could be.”

But officials are adamant that state oversight and especially “evaluation of outcomes” will be a high priority under the reorganization, and that mental health will remain high on the administration agenda regardless of its placement in the state bureaucracy.

 Among those assigned to this daunting and often thankless task is a career state administrator, Cliff Allenby, recently appointed by Gov. Brown as interim director of the Mental Health Department. A veteran state Finance Department administrator who has headed several state agencies, including the Department of Developmental Services, Allenby has no illusions about the challenges inherent in reshaping a flawed and broken mental health system.

 “We don’t have all the answers,” Allenby said. “We really don’t. The stakeholder process is very important – what should remain, and how that should be [reorganized].  I’m not here to prejudge, and we really will listen carefully at the stakeholder meetings to what they have to say, then prepare a proposal for the 2012-13 budget.”   

 “I’ve been around a long time, and Sacramento is just not the place to establish policies that work in all 58 counties,” he added, borrowing an oft-repeated anecdote from the governor’s proposals. “What works in L.A. isn’t necessarily what works in Redding.”  

Many aspects of the proposed reorganization are unknown, including the specifics of long-term funding sources and state oversight of local programs. “Somehow we must have a very high-level policy visibility that is not buried in some bureaucracy somewhere,” says the Psychiatric Association’s Hagar. “The track record hasn’t been great.”  But despite sometimes heated disagreements among the various “stakeholders,” there is widespread consensus that the administration push toward coordination of mental-health services is long overdue.

Advocates and providers are hopeful that much-touted plans for “integration of services” will carry more weight than the hollow promises of decades past.  They point to the badly fragmented system  that resulted, in which the streets, jails, prisons and state mental hospitals for the criminally insane have become both the first and last resort for the severely mentally ill, who might have been helped with earlier intervention.  

“The jails are full of people who are mentally ill, and hospitals are ringed with barbed wire and security guards,” says veteran mental-health advocate and former Assemblywoman Thomson.  “It’s the ‘trans-institutionalization’ of mental illness, and it’s tragic.”

—

Ed’s Note: Fixes title of National Alliance on Mental Illness, 4th graf.