Two-tiered mental-health system

Seven years after voters went to the polls saying they were tired of substandard community mental-health care, there is tarnish on the promise of Proposition 63.

On one side of the ledger is $7 billion in revenue for new programs, serving previously unserved clients. On the other side is a core mental-health system that is crumbling. The evidence of this includes recent killings of mentally ill persons by police while county clinics and crisis units are being shuttered, a dearth of psychiatrists willing to practice in the public mental-health system, and charges of millions of dollars in misused funds.

“This isn’t what we voted for,” said Martin McCrea, a Sacramento father, whose daughter committed suicide on November 30, after two years in the Sacramento County Mental Health Services system. She was not receiving Prop. 63-funded services because new services had to go to “previously unserved” people.

A quick refresher: Prop. 63 created the Mental Health Services Act, which was intended to provide Assembly Bill 2034-style services to both the underserved and unserved populations with serious mental illness. A.B. 2034 was the bill, authored by Senate President Pro-Tem and then-Assemblyman Darrell Steinberg, which provided what’s come to be called wraparound services to persons with serious mental illness who are also homeless.

It’s the whatever-it-takes approach and encompasses housing, medication monitoring, medical, education, employment, and social interaction. There was widespread success, in pilot project counties in reducing homelessness, hospitalization and incarceration.

“The main purpose of Prop. 63 was to expand the success of A.B. 2034 programs to whomever needed that level of care,” said Rusty Selix, co-author of the measure, along with Rose King and Steinberg. “That’s why Prop. 63 was set up.”

It did this by placing a tax on millionaires of 1 percent of every dollar over $1 million, and has raised $7.4 billion to date.

Counties had very specific mandates for spending the money: Three-quarters had to go for direct services; 20 percent must be spent on prevention and early intervention programs, while 5 percent could go for administrative services.

But King, widely regarded as the mother of Prop. 63, contends there was fraud perpetrated on the electorate who voted for one thing, but who got instead a two-tiered mental-health system of haves and have-nots.

Cadillac services … or not

In her capacity as consultant to then-Attorney General Bill Lockyer, who was also Commissioner of the Oversight and Accountability Commission, King worked closely with the state Department of Mental Health and the oversight commission on the implementation of the act in 2005 and 2006.

It was there that she saw the problems associated with the state’s performance requirements to the counties and how its mandates, she claims, created a two-tiered system. She saw a small portion of new clients receive “Cadillac services” while existing clients in the “old system” continued to wait for months to see a doctor or receive treatment.

Within the 2005-06 work plan that counties were required to submit to the state to obtain funding, they were required to answer the question: “How many of your clients are unserved or underserved/inappropriately served?”

At the time, all 58 counties reported that 95 percent of clients fell into that category.

Using the state’s definition, someone is considered “underserved/inappropriately served” if they have been diagnosed with a serious mental illness, are getting some assistance, but whose services do not provide the necessary “opportunities to participate and move forward and pursue their wellness/recovery goals.” This category would also include individuals who are so poorly served that they are at risk of homelessness, institutionalization and incarceration.

Despite this finding, however, DMH officials insisted that counties go out and recruit new clients—the previously un-served—for new programs, rather than expanding existing programs to serve existing clients.

And that, King contends, went against what voters agreed to, and is outside the scope of the law.

“That’s my beef with the system,” said King in an interview with SN&R. “Yes, there are success stories with MHSA. But the state excluded the underserved when they implemented this law, and it’s tragic. These are the people who are already being poorly served, and that’s not what people had in mind when they voted for this.”

She filed a whistle-blower complaint with the state in March 2009, and later asked, along with a handful of other citizens, for a state audit, looking into these allegations. She has yet to receive any response to her request.

Critics like King have a full roster of concerns:

• According to the most recently available data from the state, only 4.6 percent of the 443,655 Medi-Cal clients in the county mental health system statewide, received services through wraparound services.

• In 2010-11, the state is allocating more than $133.5 million for prevention and early intervention services—some of the programs claiming only loose ties to serious mental illness. For example, as some counties are not funding services for “severe” mental illness, but for “stress reduction” through “yoga, line dancing, drumming, and soul Chi (soulful movement)” and “equine-facilitated psychotherapy, and drumming for Indian youth reading below grade level or exhibiting problems.”

• Despite the influx of new funding through MHSA, the state leads the nation in cuts in mental-health spending, with $587.4 million being cut between 2009-11, according to the National Alliance on Mental Illness.

• Additionally, by the state’s own admission, no data system supported by the counties or maintained by DMH currently tracks all the clients or services that are tied to the act. As a result, outcomes are impossible to track with accuracy.

Frustration is building

Rusty Selix, Prop. 63’s co-author, and executive director of the Mental Health Association of California, concedes that the state’s mental-health department in charge of the implementation of the new law made the task of receiving funding “confusing” and onerous for counties for the first seven years of its inception.

“Our intention was that Prop. 63 would only be spent on programs that we knew worked,” Selix explained. “Many counties took that to mean that you couldn’t seamlessly transform existing programs into something that met that standard, and so they took it to mean that you had to create new programs and new clients and that was very unfortunate.”

Selix agrees it was DMH that made the error. However, neither Selix nor Steinberg agrees with King and others who charge that implementation problems have created a system of haves and have-nots.

Steinberg says the fact that the core of the state’s mental-health system is crumbling is not the MHSA’s fault—it’s the stubborn economy, and the reduction in vehicle-license fees, and sales-tax income, that is passed through to the counties to fund mental-health services through a process known as “realignment.”

“People talk about the core system crumbling,” Steinberg said. “Well, can you imagine what would happen if we didn’t have MHSA? We’d have nothing. [Prop. 63] is a gift from the taxpayer.”

“I have enormous respect for Rose King,” Steinberg said, “but this claim is misdirected. The real battle is to convince two-thirds of the Legislature to extend taxes, to raise revenue, to put toward mental health. I think the frustration that people feel toward MHSA is really aimed at a core system that’s been severely hit by the economy.”

Steinberg and Selix also point to the $400 million that’s been spent on 2,500 units of supportive housing units statewide for those with mental illness, built with funds that came with the passage of Prop. 63. About $12.3 million of which has gone to Sacramento County to build 141 units.

“MHSA is working,” said MaryAnn Bennett, director of Sacramento County Behavioral Health Services, adding that she does not believe it has created a “dual system.”

“I think it’s enhanced the county’s ability to serve the seriously mentally ill that we’re supposed to serve and without [it], I don’t know what we’d be doing.”

According to county records, in 2010-11, there were 24,000 public mental-health clients in Sacramento County 36.7 percent, of whom received MHSA-funded services. Of those, 17.3 percent received full wraparound services. The county did this with $46 million in MHSA funding.

From FY 2005-06 through 2011-12, Sacramento County received $222 million in MHSA funding according to DMH records.

That leaves 63 percent of clients receiving their services through one of five mental-health regional support teams.

This is the “bottom-tier” of the system that King talks about.

Whether counties, the voter and the mental-health consumer are getting the most bang for their buck, definitely depends on whom you speak to.

John Buck, CEO of Turning Point Community Programs in Sacramento, said his Pathways to Success after Homelessness program—an MHSA-funded wraparound-services program serving 350 clients—is a “lifesaver,”—and so is MHSA.

“I will always give Rose credit for being the mother of MHSA, but she’s wrong on this,” said Buck. “I also don’t think she understands that as MHSA becomes a major funding source, transformation takes time to move away from a risk-aversive culture, where we’re hospitalizing people, vs. keeping people in the community and believing that people can recover in the community.”

Pathways receives $3.9 million in MHSA funding annually.

But all has not been rosy for Sacramento County, as economic forces caused it to cut 50 of its long-term treatment beds at the Sacramento County Mental Health Treatment Center, as well as slash its crisis inpatient unit in 2009. As the law is written now, MHSA funds could not be used to return such services to the community, according to Bennett.

King and supporters say they don’t want to dismantle MHSA, they say, just realign state priorities to match the law’s original intent.

The change can’t come soon enough for Peter Mantas, former chair of the Contra Costa County Mental Health Commission, who said MHSA has failed to stop the intended cycling in and out of care for clients, and that efforts thus far to seek help from the state have been futile.

“You ask for qualitative measures of systemwide performance and staff looks at you as if they’re looking at ET,” said Mantas. “Instead of solving the problem, the system created disparate silos of care in an attempt to show great innovation.

Mental health crystal ball

The personal examples of tragedy related to this issue abound and are too numerous to itemize. But Carla Jacobs, co-founder of the California Treatment Advocacy Center, points to two recent incidents as examples where MHSA had no bearing on better client outcomes.

The July 5 beating death by police of Kelly Thomas, a mentally ill homeless man in Fullerton, is one such example, Jacobs said. “Thomas was known to the community, known to suffer from untreated paranoid schizophrenia, had never been violent, and had no insight into his illness. Yet, his parents could not get him into treatment, because assisted outpatient treatment [Laura’s Law] is not funded in their community. I don’t see where MHSA has helped us at all in this regard.”

Closer to home, Sacramento resident Alexander Piggee, 24, was sentenced to 15 years in state prison August 1, for the setting of the Roseville Galleria fire. According to his attorney, Johnny Griffin III, Piggee sought and was denied treatment for his mental illness the day before he went to the mall.

For Martin McCrea, the loss of his daughter, Christianne, only fuels his anger toward officials who he says refuse to look at the evidence in front of them.

In the years prior to her death, Christianne’s schizoaffective disorder and accompanying substance-abuse disorder proved a toxic combination, landing her in locked psychiatric unit after unit, again and again. At the time of her suicide, she had been living in the community in a room and board, and was destabilizing, her father said, because although she “would have stayed clean if she was required to undergo a drug test,” Christianne ended up smoking pot that night and “thoroughly destabilizing.”

“She jumped off the roof,” McCrea said, his voice, weary.

“Her last words to her mother were, ‘They need to drug test me.’” They told us in mental-health court that the drug court said it didn’t have enough money to drug test—so who do you blame?”

With the 2011-12 Budget Act, the Legislature and Gov. Jerry Brown amended the MHSA so that counties no longer need to submit plans for preapproval to receive funding each year.

The practical effect is that the state controller will simply issue checks to counties to provide services, and counties will be held accountable for complying with the law, thereby eliminating some 100 administrative positions at the state level, and countless positions throughout the state at the county level, in keeping with Brown’s effort to streamline government.

It’s unknown what the potential cost savings could be, but King and others will be keeping their eyes on where the money goes, saying that it should be flowing back into direct services.

“It’s not everything we want, but it’s a start,” King said. “People are starting to listen now.”