More than 2 million children, adults and senior citizens are affected by potentially disabling mental illnesses every year in California. The Mental Health Services Oversight and Accountability Commission (MHSOAC) shares responsibility with the Department of Mental Health, among others, for oversight of landmark 2004 legislation that shifted the focus for how the state takes care of people with severe mental illness. As a result, most government-connected mental health services are now administered by the counties but are under the supervision of the state. At its core, the Mental Health Services Act (MHSA) provides community-based mental health services and support to California residents by emphasizing collaboration between clients, their family members, and underserved communities to promote wellness for those living with serious mental illnesses. The MHSOAC also advises the governor on mental health policy, with any critical issues regarding performance being referred to the Department of Mental Health. 

The legislation that created the commission set up a separate mechanism to fund the services it provides and specifically barred the state from borrowing or otherwise commandeering the money for other purposes. This has been a bone of contention during difficult economic times. The commission, housed in the Health and Human Services Agency, consists of 16 voting members appointed for three-year terms; they receive no compensation.

Commission Overview (MHSOAC website) (pdf)

The Commission (MHSOAC website)

The state of California responded to national legislation and trends 30 years ago by slashing services in state hospitals for people with severe mental illnesses. Although the plan then was to provide mental health services in the community to compensate for the changes, adequate funding never surfaced and many people ended up homeless. In November 2004, California voters passed Proposition 63, now known as the Mental Health Services Act (MHSA), to expand and transform California’s county mental health service systems. The act is funded through a 1% tax on personal income in excess of $1 million. The first meeting of the MHSOAC was held July 7, 2005. At the meeting, Proposition 63 co-author and then-Assemblyman Sen. Darrell Steinberg was selected as chairman.

About Proposition 63 (MHSOAC website)

The Mental Health Services Act: An Important Step Toward Transformation (pdf)

The 16-member commission oversees execution of the MHSA programs that include direct services to mental health clients through contracts with California counties, programs for prevention and early intervention and housing for individuals with mental illness. The act has five components, which outline areas of responsibility for the commission.

Community Services and Supports (CSS) is the largest component of the MHSOAC. CSS is focused on community collaboration, cultural competence, client and family-driven services and systems, wellness focus, which includes concepts of recovery and resilience, and integrated service experiences for clients and families. Housing is also a major focus of the CSS component. The Department of Mental Health has funding approval of the CSS component.

Prevention & Early Intervention (PEI) helps counties implement services that promote wellness and foster health, and prevent the suffering that can result from untreated mental illness.

Innovation (INN) increases access to underserved groups and the quality of services, while also promoting interagency collaboration.

Capital Facilities and Technological Needs (CFTN) helps with the creation of  facilities used for the delivery of MHSA services to mental health clients and their families. Funds may also be used to support an increase in peer-support and consumer-run facilities, development of community-based settings, and the development of a technological infrastructure for the mental health system to facilitate services for clients and their families. The Department of Mental Health is responsible for funding approval for the CFTN component.

Workforce Education and Training (WET) develops a diverse workforce by providing training to clients and families to help promote wellness, working collaboratively to deliver client-and family-driven services, and providing outreach to unserved and underserved populations. The Department of Mental Health is responsible for its funding approval.

Counties are required to develop their own three-year plans, consistent with MHSA requirements, in order to receive funding from the commission. Counties must also collaborate with citizens and stakeholders to develop plans that will increase employment, vocational training, education, and social and community activities. Annual updates by the counties, along with a public review process, are also required.

The MHSOAC oversees the Adults and Older Adults Systems of Care Act; Human Resources; Innovative Programs; Prevention & Early Intervention Programs; and the Children’s Mental Health Services Act.

The MHSOAC annually reviews and approves county mental health program expenditures for Prevention & Early Intervention (PEI) and Innovation programs.  The Commission has review and comment responsibility for Community Services and Supports (CSS), Capital Facilities and Technological Needs, and Workforce, Education and Training programs.

The commission itself represents a wide-range of sectors that are affected by and have the potential to contribute to the mental health of California’s citizens. Commissioners include the Attorney General, the Superintendent of Public Instruction, the chairperson of the Senate Health and Human Services Committee, the chairperson of the Assembly Health Committee, and 12 individuals to be chosen by the governor, including:

·        two persons with a severe mental illness.

·        a family member of an adult or senior with a severe mental illness.

·        a family member of a child who has or has had a severe mental illness.

·        a physician specializing in alcohol and drug treatment.

·        a mental health professional.

·        a county sheriff.

·        a superintendent of a school district.

·        a representative of a labor organization.

·        a representative of an employer with less than 500 employees.

·        a representative of an employer with more than 500 employees.

·        a representative of a health care services plan or insurer.

Capital Facilities (MHSOAC website)

About Commission Components (MHSOAC website)

Duties, Responsibilities and Composition of the Commission (MHSOAC website) (pdf)

By law, the State Controller transfers specified amounts of money annually from the state’s General Fund to the Mental Health Services Fund for support of Prop. 63 mandated services. All of the commission’s administrative funding, $5.5 million in 2011-12, comes from that source and is used for operating expenses and personnel. The Prop. 63 tax generates more than $1 billion a year in state and (matching) federal funds to support the programs overseen by the commission, the Department of Mental Health and other entities. But support for those programs does not flow budgetarily through the commission.

Mental Health Advocates See Promise, Problems in Budget Plan (by George Lauer, California Healthline)

Skimping on Mental Health Has Consequences (by George Lauer, California Healthline)

3-Year Budget (pdf)

Schwarzenegger Vetoes Funds for Mentally Ill

In August 2007, Governor Arnold Schwarzenegger vetoed $55 million for a mentally-ill, homeless adults program, saying the money could be made up from Proposition 63 funds. The cut was perhaps the most controversial item among the $700 million worth of line-item vetoes he delivered to break a budget impasse. Funding for the program, considered a model for Proposition 63, had been authorized in 2000 under Assembly Bill 2034 and had been fully funded every year since. 

The focus of dispute centered on a provision in Proposition 63 that prohibited the state from dropping below its 2004 funding levels for mental health – funding that was in place when voters approved Proposition 63. That portion of the law was written to prevent the state from using the new funding for old programs, rather than build on them with new programs.

Mental health advocates believed that that part of the law, known as the  “maintenance of effort” provision, should be interpreted strictly – meaning that funding for the mental health system must be protected on a program-by-program basis. The state argued that since it had increased funding in some mental health areas it could cut funding in others. But state Sen. Darrell Steinberg, who co-wrote Proposition 63, said the increase cited was for children, while Proposition 63 was targeted at the homeless-mentally ill. “Under no scenario or circumstance did I, as one of the authors, ever contemplate that the state would be able to cut core mental health funding,” Steinberg said.

As a result of the veto, a program that helped nearly 5,000 mentally ill homeless people with housing, employment and other services shut down in 34 of the state’s 58 counties, leaving counties scrambling to find alternative ways of providing services.

Mental health advocates sued the governor but lost in Superior Court and in the Court of Appeals. The State Supreme Court declined to review the case.

Mental Health Funding Dispute Could Go to Court (by Scott Gold and Lee Romney, Los Angeles Times)

Mental Health Advocates Sue Governor to Restore Vital Program (National Center for Youth Law)

Mental Health Shift Sparks Suit (by Andy Furillo, Sacramento Bee)

CA Court of Appeal Upholds Elimination of Homeless Individuals’ Mental Health Program (National Center for Youth Law)

Jensen v. Franchise Tax Board (Find Law) 

Restructuring

A major component of Governor Jerry Brown’s proposed government restructuring in 2011 involved the shifting of authority and funding for mental health from the state to counties. Brown proposed a move of $861 million in Proposition 63 funds from the state General Fund, but only for one year. It is uncertain where the funding for these programs would come from after that. Governor Brown proposed that the future funding would come from a five-year extension of higher tax rates, but legislators balk at putting it on the ballot and polls show voters are way of voting for it. The $861 million funds three programs: a mandated Medicaid offering designed to improve the health of low-income children, managed care health services and state-mandated mental health services for special education students.

In anticipation of the three programs being spun off and creation of a new Department of State Hospitals, Governor Brown also proposed elimination of the Department of Mental Health. It was uncertain what the consequences for MHSOAC would be.

Reducing State Government (Ebudget, Proposed 2011-12) (pdf)

Health and Human Services (Ebudget, Proposed 2011-12)

Proposition 63: The Right Thing to Do?

When Californians passed Proposition 63 by a 54-46 margin they hoped to improve the lives of some of society’s most at-risk citizens, the mentally ill. The law especially targeted those who were homeless and young. Was it the right thing to do?

Yes

Government isn’t perfect. It’s not hard to find inefficiencies in any bureaucracy – maddening compromises, startling incompetence, conflicts of interest and undue influence from special interests. It’s all part of the frustrating institution that tries to provide order, justice and compassionate assistance to a diverse constituency that numbers in the millions.

The Mental Health Services Oversight and Accountability Commission thinks Prop. 63 has been a success and rattled off a list of accomplishments in its report to the governor and Legislature in 2011.  As of November 2010, $5.1 billion had been distributed to counties, including $734.9 million for Prevention and Early Intervention and $175.5 million distributed for Innovation programs. One evaluation by UC Berkeley’s Nicolas C. Petris Center found that after 12 months of participation in Full-Service Partnership (FSP) Programs, a key strategy of the law, the proportion of mental health consumers living independently increased by nearly 20%, mental health-related emergency services declined 67%, the probability of being arrested dropped by 56%, and employment outcomes were improved by 25%. 

Much of the state’s contribution to implementing the Mental Health Services Act is facilitating activities at the local level by reviewing and approving county plans. The commission approves funding for two of the five program components it oversees and provides review and comment on the other three. (The Department of Mental Health has a reverse input on the five components.)  All 58 counties have participated in the largest component, Community Services and Supports, and nearly all are administering funds for Prevention and Early Intervention.

The Los Angeles County Department of Mental Health reported in 2010 a 40% drop in clients under the age of 18 being hospitalized at psychiatric facilities. Adults under the age of 60 had dropped 44% and the number of older adults had declined 42%. The change in homeless rates was an even more dramatic 64% for adults. Days of adult incarceration by adults was off 38%. County officials claimed big savings too: $39.8 million from drops in hospital and jail stays alone. The department’s district chief, Debbie Innes-Gomberg, said the Prop. 63 money was directly responsible for much more favorable case-worker-to-client ratios, which were critical to successfully helping the mentally ill.

A more personal story of success was related by Frank Woodard, who sat on a steering committee for transitional youth in Orange County. In response to Rose King’s lament about how the legislation she had helped create was failing to accomplish its goals, Woodard told the story of one youth, in one county, in one program. Prior to his enrollment in an MHSA program, the boy had seven psychiatric hospitalizations over the span of four years. Some of the hospitalizations lasted five months. After enrolling in an MHSA program, he had no hospitalizations, lived independently and took his meds on schedule.   

Along with those successes were some failures, but from it all, the commission maintained, it had laid the groundwork for greater success in the future by putting in place ongoing evaluation systems that “could lead to a greater understanding of impact of the MHSA on the public mental health system.”

First Report to the Governor and Legislature (MHSOAC website) (pdf)

Prop. 63 Yields Results In L.A. County (Payers & Providers) (pdf)

Proposition 63: How Did It Happen? (Mental Health America of California)

No

Some opponents of Prop. 63 argued it was unfair to target so blatantly one class of people (the wealthy) for taxation no matter how worthy the cause. Others opposed the proposition because it was a tax “set-aside” that narrowly dictated how the money would be spent. Mandatory set-asides make up more than half the state spending obligations and hamstring politicians trying to allocate the remaining discretionary funds. Both argued that over time, inflation and economic growth would combine to jack up the size of the Prop. 63 pot and pour more money into helping the mentally ill homeless than was originally envisioned.

Shortly after it became law, Prop. 63 drew fire from those who felt its sponsors had lied about its particulars and demanded a do-over at the ballot box. It was never made clear, they argued, that the “millionaire’s tax” would be applied to married couples, so in their minds some individuals with incomes of $500,000 would be unfairly dinged. One think tank gave the law a “Golden Fleece” award and cited newspaper articles that referred to the “individual” $1 million tax threshold as well as what it considered misleading wording in the proposition’s text and voters guide.

A report released in January 2010 claimed that the law had been a failure. Zeroing in on an aspect of the proposition that promised to direct new funds at “transition age youth” with some of the highest rates of mental illness, the Children’s Advocacy Institute at the University of San Diego School of Law in a press release said the money was not reaching foster children. “The Report grades the counties on their use of Mental Health Services Act (Proposition 63) funding to address the needs of Transition Age Foster Youth.  Twenty-six counties, home to over 78% of California’s Transition Age Foster Youth, received a failing grade.” Foster youth “get next to nothing while funding for prisoners and so-called ‘stigma reduction’ programs get millions of dollars.”

Critics of the law aren’t the only people who question its effectiveness. Rose King, a legislative staffer who was one of the earliest proponents and a principal architect of Prop. 63, gave the law a failing grade on its fifth anniversary. “Billions in new taxes have had minimal impact on local systems, access is rationed, and consumers are still denied services essential to recovery. Counties do not report advances in program standards for those 700,000 clients who were not fully served when Prop 63 passed.”

In a Whistleblower Complaint she filed with the State Auditor, King complained that mismanagement, incompetence and state policies created an unnecessary, fragmented and inefficient bureaucracy. Tax revenues were being diverted from needy programs to “a separate system for unknown and unexplained purposes” and officials were failing to craft a functional structure that avoided conflicts of interest and special interest influences.

Critics of the law also aim their fire at the officials who administer and defend it. The Hospital Association of Southern California (HASC) disputed claims by the Los Angeles County Department of Mental Health that hospitalizations had dropped because of MHSA. “If they’re looking at the overall effectiveness of their programs, they get an ‘F’ grade,” said HASC Executive Vice President Jim Lott. He said that the region’s emergency rooms are filled with mentally unstable patients that should be hospitalized but instead end up in facilities that are often forced to hold them voluntarily for up to 72 hours.

Vote “No” on Prop 63 (Pete Rates the Propositions)

Whistleblower Says Prop 63 Not Working in Cal. (by Rose King, MIWatch.org)

Golden Fleece Award (Pacific Research Institute)

Proposition 63 Breaks Promises (Children’s Advocacy Institute) (pdf)

Andrew Poat, 2008 – 2010

Linford Gayle, 2008

Darrell Steinberg, 2005 – 2007. Steinberg, a Democrat from Sacramento, was elected to the state Assembly in 1998 and in 2004 co-authored Proposition 63, which created MHSOAC.  The law was based on pilot programs he had championed in the Assembly. He was unanimously elected the commission’s first chairman. He left the Assembly in 2004 and was elected to the state Senate in 2006 where he became President pro Tempore in 2008.