Real change proves elusive in mental health care system

Important legislation to improve California’s broken mental health system was passed this year, plus billions in new funding in the state budget — all aimed at stemming the tide of a growing crisis on California streets, in hospital ER’s, jails and prisons.

But will it mean real change?

Longtime mental-health advocates and public officials welcome the intense interest in a badly neglected area of government policy.

But some question whether ever-growing infusions of cash and new laws will effectively change a system hobbled by competing bureaucracies, entrenched stigma and a baffling lack of comprehensive statewide data on the effectiveness of old and new programs.

Many say a complete overhaul is needed.

“While it’s amazing to see the magnitude of  interest [and] budget investment, it’s disquieting that there isn’t a better sense of cohesion and coherence in the solutions,” said Randall Hagar, who has written much of the legislation and policy analyses for major bills as a legislative advocate for the Psychiatric Physicians Alliance of California, which represents psychiatrists.

The result, he says, is a “bushel of ideas,” but limited systemic change. “We’ve had two decades of really encouraging sound bites, but we still have the same number of people homeless and mentally ill, the same number in jails and prisons.”

A homeless man lying on the sidewalk in front of a Beverly Hills bank. Experts see clear links between homelessness and mental illness.(Photo: Joseph Sohm, via Shutterstock)

Crippling the efforts for fundamental change is the Legislature’s apparent inability to pass major legislation that significantly alters the 1967 Lanterman-Petris-Short Act (LPS), which has dictated California’s mental health policy for more than 50 years.

One of the few major changes to LPS was passed nearly two decades ago, giving family members a legal avenue to get severely mentally ill relatives into intensive treatment. “Laura’s Law” was strengthened and finally made permanent by state Sen. Susan Talamantes Eggman’s legislation last year, and further enhanced in another bill this year by Eggman (D-Stockton).

The original 2002 law, by then-Assemblywoman Helen Thomson (D-Davis), was named for 19-year-old Laura Wilcox, who was killed in 2001 while working during her winter break from college at a Nevada County mental health clinic. Her killer was a deranged clinic patient whose family had warned authorities about his condition, but were ignored.

Laura Wilcox (Family photo)

While widely praised as a major breakthrough — successfully coaxing more people into voluntary treatment, reducing incarceration, homelessness and hospitalizations, and saving public funds — the law is limited to severely mentally ill people who fit certain criteria. Mental health experts say more needs to be done to treat mental illness before it becomes severe – spurring a major push this year to provide better treatment, and funding, for children and youth.

Suicide 2nd leading cause of death for ages 10-24
Motivated in part by an alarming increase in mental-health crises among young people, especially during the isolation, loneliness and loss of COVID, one of the largest expenditures in the state budget is a five-year, $4.4 billion Children and Youth Behavioral Initiative aimed at better screening, intervention, and treatment for youths up to age 25.

It comes at a time when suicide is the second leading cause of death for young people aged 10-24, according to the Centers for Disease Control — a number that has increased by 60 percent between 2007 and 2018, before the pandemic, escalating even further during COVID.

“Half of all lifetime cases of diagnosable mental illnesses begin by age 14,” and three-fourths by age 25, said Dr. Mark Ghaly, a pediatrician who is Secretary of the state Health and Human Services Agency. He is particularly focused on improved services for kids.

“There’s no universal place to go if a young person is struggling with stress, anxiety, depression — or something more serious,” he wrote in a recent article . “There is too little focus on prevention, too few programs, too few behavioral health professionals, too few emergency services, and too few hospital beds for young people with mental health and substance use issues.”

But getting older teens – or anyone over the legal age of 18 —  into treatment also faces a plethora of barriers under the extremely restrictive provisions of Lanterman-Petris-Short, which established a cumbersome legal system of limited “mental health holds” – the “5150’s” of mental health law, a reference to the state Welfare and Institutions Code, which requires proof of “a danger to themselves or others.” Even then, mental-health holds usually last only 72 hours, hardly time enough for actual treatment, or any treatment at all.

When it was passed in 1967, LPS was regarded as a major “reform” measure, a reaction – many now say an overreaction — to widespread abuse of civil liberties, injuries and deaths in a vast system of state mental hospitals which were largely closed in the 1960s and ‘70s, with stringent limits placed on compelling treatment.

State Sen. Susan Talamantes Eggman (D-Stockton). (Photo: Senate staff)

But the community care designed to take their place never materialized, and the result is legions of mentally ill people — many with drug addictions from “self-medicating” because they aren’t receiving treatment – who are living on the streets, cycling through hospital ER’s, and jails, usually for petty crimes or behavior related to their mental illness.

‘The new asylums’
Jails and prisons have become de facto mental institutions, the “new asylums,” ill-equipped to help or even house mentally ill inmates.  Many are jailed for months, even years, because of a growing backlog of defendants — charged but not tried — awaiting “mental competency” evaluations in the remaining state mental hospitals, which primarily house those deemed criminally insane by the courts.

Legislation to address mental health and related issues like substance abuse, homelessness and incarceration, has been introduced for years, often unsuccessfully, and only recently has the state started to take a hard look – and provide significant funding.

The landmark Mental Health Services Act, the so-called “millionaire’s tax” passed by voters as Proposition 63 in 2004, has provided billions in funding for mental-health programs, but has also been criticized for its complex regulatory structure and lack of state oversight. Counties have also been accused of “hoarding” MHSA funds that should be going to mental-health programs, or using it for other purposes.

In addition to multiple bills enacted this year, hearings are scheduled during the legislative recess to examine possible broad changes to LPS. A Behavioral Health Task Force  appointed by Newsom last year is ramping up its public meeting schedule, and there is talk of a ballot initiative to enact a major overhaul.

A view of a homeless encampment along Central Avenue in downtown Los Angeles. (Photo: Matt Gush, via Shutterstock)

The outlook appears positive.

“I’m excited that the next few years will be transformative,” Eggman, a former social worker and Sacramento State professor who has long been in the forefront of major mental-health legislation, told Capitol Weekly in a recent interview. “We can make a difference and fix a system that we all acknowledge is broken, and help people.

“The governor’s budget includes significant funds for mental health and homelessness. The very wealthy have done very, very well in the stock market. We should use some of that money to lift up the least of us.”

“Maybe we could take these [mental-health] issues to the voters and ask them,” Eggman added. “We cannot ask for changes in the law (Lanterman-Petris-Short) unless we have the infrastructure” – including treatment facilities and housing that are in short supply throughout the state.

Eggman has opened a campaign committee for a possible ballot measure.

Among other bills this year, Eggman’s SB 516 would have redefined “grave disability” (often the standard for mental-health treatment under LPS) by allowing courts to consider a person’s ability to manage a serious physical health condition when determining if they present a danger to themselves under LPS. The measure passed unanimously in the Senate, but was held – along with several other bills involving changes to LPS – in the Assembly Health Committee, which called for more in-depth hearings on the history and future of LPS.

Joint LPS hearing Dec. 15
A joint hearing of the Assembly Health and Judiciary Committees is scheduled Dec. 15, and is expected to guide legislators in crafting comprehensive LPS legislation next year.

Other important bills were also tabled or extended into next year, including Eggman’s  SB 316, which would have enabled clinicians to bill Medi-Cal for more than one medical condition per visit (e.g., treatment for a physical ailment and a mental health disorder). The measure has failed repeatedly over the past 17 years — despite widespread support for coordinated care — but can be revived next year by the author.

A related budget item that failed last year was revived this year. It would provide funding for mental-health training for primary care physicians – who are often the first point of contact for patients experiencing mental-health crises. The state budget includes $9.5 million to fund Primary Care Psychiatry fellowships at the UC-Irvine School of Medicine.

As the lingering COVID pandemic shined a bright light on the stark failures of a cumbersome, outdated system, legislators introduced dozens of bills to strengthen existing laws, and create new programs. Those ranged from measures to target mental health crises among children and teens to a statewide response system for mental-health calls that includes social workers and clinicians, rather than going directly to law enforcement, with often disastrous results.

While local governments are establishing alternative response systems throughout the state, a much-publicized California measure, AB 988, by Assemblywoman Rebecca Bauer-Kahan, D-Orinda, was passed unanimously in the Assembly, but became mired in the legislative process, and was extended into next year for further discussion.

Named for Miles Hall, a 23-year-old mentally ill Black man who was shot and killed by Walnut Creek police officers in 2019 after his family called for help, the measure would implement 2020 federal legislation establishing a national “988” phone line for suicide prevention and mental health crises. Walnut Creek city officials last year announced they had reached a $4 million settlement with Hall’s family.

For his part, Newsom traveled the state, holding press conferences (while also, successfully fighting a recall) to announce major funding for a dizzying array of ambitious programs to tackle one of California’s most persistent and intractable public health emergencies.

In a recent Capitol Weekly conference on “California’s Mental Health Crisis,” Ghaly, who heads the state Health and Human Services Agency, which is leading the charge in the Newsom administration’s plans to address mental health, called the pandemic “the great unmasker of disparities and inequities, and the great accelerant for change.”

Michelle Cabrera, executive director of the influential County Behavioral Health Directors Association of California, said stigma remains, despite growing public support for mental health programs. “We’re on the precipice of change,” she said at the conference, “But stigma is still there, and unconscious bias,” which too often thwart local and state efforts to get mentally ill and homeless people off the streets, into housing and treatment, and keep them out of jail.

A homeless man sits alone in the shadow of a building. (Photo: Followtheflow, Shutterstock).

‘A fragmented system’
“We struggle with a fragmented system,” said Dr. Elaine Batchlor, CEO of the MLK Community Health System in Los Angeles, who also spoke at the conference. Despite laws requiring “parity” or equal treatment of mental-health and physical conditions, current insurance and reimbursement requirements – both publicly funded Medi-Cal and private insurers – too often treat mental health and substance abuse separately from physical care.

Batchlor and many other public-health experts say mental-health issues are more effectively (and much less expensively) addressed in a coordinated system of care, so that patients in crisis, who often also have major physical conditions exacerbated by homelessness and poor medical care, are treated under one health-care umbrella.

“We need more acute stabilization units,” she said. “If we can find resources for people in crisis, we can avoid hospitalizations.”

While dozens of bills were introduced this year – Hagar said he was following at least 65 mental-health bills as a legislative advocate for psychiatrists – many failed to gain traction, and some were vetoed by the governor. Others were continued for further hearings into next year. But several major bills were passed, often with unanimous, bipartisan support — plus significant funding in the state budget, federal funds, and Newsom’s well-publicized support for programs to aggressively address mental illness, homelessness and incarceration.

“I’ve really been struck – and pleasantly surprised – by how bipartisan the votes were on so many of these bills,” says Julie Snyder, government relations director for the Steinberg Institute, the mental-health advocacy organization established by former state Senate President, now Sacramento Mayor, Darrell Steinberg, who was the author of the Mental Health Services Act.

“COVID actually accelerated that. Every legislator, lobbyist and staffer has experienced the mental-health impacts of isolation. There is heightened recognition — not that the solutions come more easily,” she said.

Advocates caution, however, that the real work often begins after bills become law — ensuring that the intent of the legislation is actually carried out by state and local government.

“There is tremendous work to be done to ensure that the concepts in the bills and in the governor’s budget are effectively implemented,” says Hagar, pointing to lax, uneven implementation in the 30 counties  that now have some form of “Laura’s Law,” which passed in 2002 and was only recently strengthened and expanded, though still not available in every county. “As we’ve learned with Laura’s Law, implementation can be a bitch.”

Often hampering implementation is a dearth of reliable statewide data collection– to determine how well or how poorly state and local programs succeed in reducing such markers as repeat hospitalizations, homelessness, incarceration. Lack of good data – and followup care for patients released from treatment, or conservatorships – were major criticisms by state Auditor Elaine Howle in a scathing report last year that specifically addressed Lanterman-Petris-Short.

Howle was particularly critical of state oversight of programs primarily run by California counties, which receive billions in federal and state funds for mental health, with little statewide coordination or comprehensive data collection.

Laura’s Law, for example, requires that the state Department of Health Care Services maintain program statistics from the counties, and issue regular reports, but advocates say the data provided is too often confusing and incomplete. 

“There is a lack of statewide data collection, but also a lack of accountability for poor program performance,” says Hagar, who helped write the original Laura’s Law, as well as recent bills to strengthen it, “so we can look at the history, see what patterns emerge.” 

Summary of major 2021 mental health bills
This is by no means a comprehensive list of mental health legislation passed this year. More complete descriptions, and more bills, can be found on several legislative and advocacy websites, including the Steinberg Institute  and the National Alliance on Mental Illness — California. 

Below are the authors and summaries of several major mental health bills passed by the Legislature this year and signed by Gov. Newsom. Many bills have several co-authors.

—SB 465, by Eggman, provides for better use of state funds by using “evidence-based outcome measurements” in mental-health care (e.g., measuring the effectiveness of programs in keeping people out of jail, hospitals, homelessness), passed unanimously.

—SB 507, by Eggman, further expands Laura’s Law (Assisted Outpatient Treatment, AOT), passed unanimously. It provides for a clinical determination that the person is “unlikely to survive safely in the community without supervision,” that the person’s condition is not only “substantially deteriorating” (the existing standard), but also that assisted outpatient treatment is needed to “prevent deterioration” that would likely result in grave disability or serious harm to that person or to others. The bill also authorizes the filing of a petition to obtain assisted outpatient treatment for a person who is about to be released from conservatorship. 

—SB 317, by Sen. Henry Stern (D-Los Angeles), expands current law governing treatment options for people accused of crimes who are thought to be mentally ill. If a defendant is found incompetent to stand trial on a misdemeanor charge, the court could refer that defendant to diversion or community treatment programs, consider a referral to a conservatorship proceeding or dismiss the charges. If defendants are confined pending a trial in a state hospital or treatment facility, they would be eligible for partial credit against a subsequent sentence for the time they spent in the facility.

—AB 816, by Assemblyman David Chiu (D-San Francisco), appropriates approximately $130 million annually to build apartments for homeless people living with severe mental illness, including “wrap-around” support services.

—SB 14 and SB 224, by Sen. Anthony Portantino (D-La Canada-Flintridge), to address a growing mental-health crisis among children and youth in California schools by implementing procedures to educate students and staff about mental health, and ensure that school absences for mental health issues are excused in the same way as absences for physical illness.

—SB 428, by Sen. Melissa Hurtado (D-Sanger), requires private health insurers to cover screening for Adverse Childhood Experiences (ACEs) — traumatic events in a child’s life (such as violence, abuse and neglect) which are increasingly known to cause or exacerbate mental illness in children, who can be helped with early identification and treatment.

—SB 221, by Sen. Scott Wiener (D-San Francisco), requires health providers and insurers to schedule follow-up appointments with psychotherapists or other non-physician specialists within 10 days of an initial appointment for a non-urgent mental health or substance use disorder.

Providers are now required to schedule an initial appointment with a clinician within 10 days of a person seeking help, but it is often weeks before people can get a follow-up appointment.

—AB 118, by Assemblywoman Sydney Kamlager (D-Los Angeles), enacts the Community Response Initiative to Strengthen Emergency Systems Act (C.R.I.S.E.S.), to provide grants for community-based pilot programs that reduce reliance on law enforcement agencies as first responders in crisis situations that are unrelated to a fire department or emergency medical service response.
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Editor’s Note: Editor’s Note: Sigrid Bathen is a Sacramento journalist and former Sacramento Bee reporter who taught journalism at Sacramento State for 32 years. She has long covered mental-health issues, for several publications, and her writing has won numerous awards. She has covered health care, education and state government for Capitol Weekly since 2005. Her web site is www.sigridbathen.com. She can be reached at [email protected].