In November 2004, voters in the U.S. state of California passed Proposition 63, the Mental Health Services Act (MHSA), which has been designed to expand and transform California's county mental health service systems. The MHSA is funded by imposing an additional one percent tax on individual, but not corporate, taxable income in excess of one million dollars. In becoming law in January 2005, the MHSA represents the latest in a Californian legislative movement, begun in the 1990s, to provide better coordinated and more comprehensive care to those with serious mental illness, particularly in underserved populations. Its claim of successes thus far, such as with the development of innovative and integrated Full Service Partnerships (FSPs), are not without detractors who highlight many problems but especially a lack of oversight, large amount of unspent funds, poor transparency, lack of engagement in some communities, and a lack of adherence to required reporting as challenges MHSA implementation must overcome to fulfill the law's widely touted potential.
Background
At one time, California was known for having a strong mental health system. Treatment was available for Medi-Cal recipients with few limitations on care. Legislators and voters have acknowledged the inadequacy of California's historically underfunded mental health system to care for the state's residents, especially those with serious mental illness, over the past few decades. In 1991, to build a more community- and county-based system of care, the California legislature instituted realignment, a delegation of the control over mental health funds and care delivery from state to county. This was followed by a succession of legislation targeted towards marginalized populations with high documented rates of mental illness, such as the homeless (AB 2034, in 1999) and the potentially violent mentally ill (Laura's Law, in 2002). However, with the passage of Proposition 63 in 2004, California voters acted upon a widespread perception that state and county mental health systems were still in disrepair, underfunded, and requiring a systematic, organizational overhaul. This perception echoed a nationwide perspective, with the President's New Freedom Commission on Mental Health in 2003 calling for fundamental transformation of the historically fragmented mental health system. The MHSA is California's attempt to lead the way in accomplishing such systemic reform.
In the end, voter consciences were pricked by the well-organized and -funded campaign that displayed both the need (50,000 mentally ill homeless people, according to the National Alliance on Mental Illness) and the promise (successes of past mental health initiatives) of increased funding for the mental health system. Then-Assemblyman Darrell Steinberg and Rusty Selix, executive director of the Mental Health Association in California, led the initiative by collecting at minimum 373,816 signatures, along with financial ($4.3 million) and vocal support from stakeholders. Though Governor Arnold Schwarzenegger and the business community were opposed to Proposition 63 because of the tax it would impose on millionaires, the opposition raised only $17,500. On November 2, 2004, Proposition 63 passed with 53.8% of the vote, with 6,183,119 voting for and 5,330,052 voting against the bill.
Overview
The voter-approved MHSA initiative provides for developing, through an extensive stakeholder process, a comprehensive approach to providing community based mental health services and supports for California residents. Approximately 51,000 taxpayers in California will be helping to fund the MHSA through an estimated $750 million in tax revenue during fiscal year 2005–06.
The MHSA was an unprecedented piece of legislation in California for several reasons: Its funding source, quantity, and allocation is dedicated for mental health services, including times of budget cuts to many other public programs It was intended to engage communities in prioritizing which service elements would be funded. It was focused on developing preventive and innovative programs to help transform the mental health care system in California.
To accomplish its objectives, the MHSA applies a specific portion of its funds to each of six system-building components: Community program planning and administration (10%) Community services and supports (45%) Capital (buildings) and information technology (IT) (10%) Education and training (human resources) (10%) Prevention and early intervention (20%) Innovation (5%)
Notably, none of the funds were to be used for programs with existing fund allocations, unless it was for a new element or expansion in those existing programs. At least 51% of the funds have to be spent on community services and support for children and adults with or at risk of developing mental illness.
The MHSA stipulates that the California State Department of Mental Health (DMH) will contract with county mental health departments (plus two cities) to develop and manage the implementation of its provisions. Oversight responsibility for MHSA implementation was handed over to the sixteen member Mental Health Services Oversight and Accountability Commission (MHSOAC) on July 7, 2005, when the commission first met.
The MHSA specifies requirements for service delivery and supports for children, youths, adults and older adults with serious emotional disturbances and/or severe mental illnesses. MHSA funding will be made annually to counties to: Define serious mental illness among children, adults and seniors as a condition deserving priority attention, including prevention and early intervention services and medical and supportive care Reduce the long-term adverse impact on individuals, families and State and local budgets resulting from untreated serious mental illness Expand the kinds of successful, innovative service programs for children, adults and seniors already established in California, including culturally and linguistically competent approaches for underserved population Provide State and local funds to adequately meet the needs of all children and adults who can be identified and enrolled in programs under this measure Ensure all funds are expended in the most cost-effective manner and services are provided in accordance with recommended best practices, subject to local and State oversight to ensure accountability to taxpayers and to the public
Implementation
Starting from enactment, implementation of the MHSA was intended to take six months; in reality, the process of obtaining stakeholder input for administrative rules extended this period by several months. By August 2005, 12 meetings and 13 conference calls involving stakeholders across the state resulted in the final draft of rules by which counties would submit their three-year plans for approval.
Counties are required to develop their own three-year plan, consistent with the requirements outlined in the act, in order to receive funding under the MHSA. Counties are obliged to collaborate with citizens and stakeholders to develop plans that will accomplish desired results through the meaningful use of time and capabilities, including things such as employment, vocational training, education, and social and community activities. Also required will be annual updates by the counties, along with a public review process. County proposals will be evaluated for their contribution to achieving the following goals: Safe and adequate housing, including safe living environments, with family for children and youths Reduction in homelessness A network of supportive relationships Timely access to needed help, including times of crisis Reduction in incarceration in jails and juvenile halls Reduction in involuntary services, including reduction in institutionalization and out-of-home placements
MHSA specifies three stages of local funding, to fulfill initial plans, three-year plans, and long-term strategies. No services would be funded in the first year of implementation. The DMH approved the first county plan in January 2006. Allocations for each category of funding were planned to be granted annually, based upon detailed plans with prior approval. However, an amendment to the MHSA, AB 100, which passed in March 2011, serves to streamline the DMH approval and feedback process to the counties, ostensibly to relieve the DMH of some of its administrative burden.
Roles and responsibilities
While the county mental health departments are involved in the actual implementation of MHSA programs, the MHSA mandates that several entities support or oversee the counties. These include the State Department of Mental Health (DMH) and the Mental Health Services Oversight and Accountability Commission (MHSOAC).
California State Department of Mental Health (DMH)
In accordance with realignment, the DMH approves county three-year implementation plans, upon comment from the MHSOAC, and passes programmatic responsibilities to the counties. In the first few months immediately following its passage, the DMH has: Obtained federal approvals and Medi-Cal waivers, State authority, additional resources and technical assistance in areas related to implementation Established detailed requirements for the content of local three year expenditure plans Developed criteria and procedures for reporting of county and state performance outcomes Defined requirements for the maintenance of current State and local efforts to protect against supplanting existing programs and their funding streams Developed formulas for how funding will be divided or distributed among counties Determined how funding will flow to counties and set up the mechanics of distribution Established a 16-member Mental Health Services Oversight and Accountability Commission (MHSOAC), composed of elected State officials and Governor appointees, along with procedures for MHSOAC review of county planning efforts and oversight of DMH implementation Developed and published regulations and provide preliminary training to all counties on plan development and implementation requirements
The DMH has directed all counties to develop plans incorporating five essential concepts: Community collaboration Cultural competence Client/family-driven mental health system for older adults, adults and transition age youth and family-driven system of care for children and youth Wellness focus, which includes the concepts of recovery and resilience Integrated service experiences for clients and their families throughout their interactions with the mental health system
The DMH, in assuming and asserting its primacy over MHSA implementation, has dictated requirements for service delivery and supports as follows: Full Service Partnership (FSP) Funds - funds to provide necessary services and supports for initial populations General System Development Funds - funds to improve services and infrastructure Outreach and Engagement Funding - funds for those populations that are currently receiving little or no service
Mental Health Services Oversight and Accountability Commission (MHSOAC)
The authors of the MHSA created the MHSOAC to reflect the consumer-oriented focus of the law, mandating at least two appointees with severe mental illness, two other family members of individuals with severe mental illness, and various other community representatives. This diverse commission holds the responsibility of approving county implementation plans, helping develop mental illness stigma-relieving strategies, and recommending service delivery improvements to the state on an as-needed basis. Whenever the commission identifies a critical issue related to the performance of a county mental health program, it may refer the issue to the DMH.