By Rose King*
In 2004, California approved Proposition 63, a historic victory expected to transform the state's ailing mental health system. Voters made good on a 40-year old promise to fund community services, when their elected officials could not do the job. As a coauthor of the measure, I believed the clear language of the law guaranteed expansion of proven programs. We could finally afford a system that works.
The magnitude of need was well known in California's fragmented and crisis-driven system, where counties reported in 2005 that virtually all mental health clients were poorly served. (California is a county-controlled service system.) Prop 63, known as the Mental Health Services Act (MHSA), was supposed to change this picture.
But today, five years after passage, 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 700,00 clients who were not fully served when Prop 63 passed.
In Sacramento County where I live, 4,500 consumers were told in August not to return to see their clinic doctor or get medications; news media report that budget cuts are crowding emergency rooms. Volunteer stakeholders on county committees throughout the state filed grievances with every agent of recourse, and appealed to an Oversight and Accountability Commission (OAC) created by the MHSA. Comments from diverse areas of the state were similar in a 2008 survey by the National Alliance for Mental Illness (NAMI) California. They said: "It seems that more $$ are spent on planning, meetings, than are actually being spent in service...None of our family members were receiving adequate services before Prop 63 and now they are receiving even less...It is definitely unfair and discriminating"
The discrimination and diversion of funds became apparent as the state rolled out its implementation plans. The Department of Mental Health (DMH) required counties to budget the majority of funds for new programs to serve new clients, launching a "Two-Tier" system in which poorly served clients in existing programs could expect little benefit from the MHSA. As a consultant to California's Attorney General, a member of the OAC, I witnessed and reported on the state's performance.
Last November, on the fifth anniversary of passage of Prop 63, I filed a Whistleblower Complaint with the California State Auditor. My complaint makes the following allegations:
1. Tax revenues intended to expand community mental health programs and raise standards of service were diverted to create a separate system for unknown and unexplained purposes;
2. Waste of time and money resulted from mismanagement, incompetence, and state policies that created a fragmented, inefficient, and unnecessary new bureaucracy, and an industry of unnecessary planning;
3. Officials failed to establish a functional structure and process to implement the law, operating without known standards and objectives, and inviting potential conflicts of interest and special interest influences.
Grievances, attached to a press release, include the following:
•More than $6 billion has been collected in taxes, but very little is allocated to county improvements, and at least a billion of last year's revenue idles in a state fund. In May 2008, Governor Schwarzenegger's own Department of Finance issued a scathing evaluation of MHSA implementation in a DMH audit. Three years after passage, only one quarter of the taxes collected were distributed to the counties, and the process was inefficient, delayed, insufficiently documented, and not compliant with the law.
• Funding is stalled because the state required new programs and rejected the proven service systems. Auditors called for a total of 19 "corrective actions," and said the state needed "a strategic development and implementation plan...and one set of comprehensive, integrated guidelines for all components." Despite state administrative costs approaching $50 million a year, the DMH has not published an official plan explaining policies or expenditures.
•The state's "Two-Tier" system and disjointed implementation generates needless state and local bureaucracies, along with county planning now in its sixth year of working on six separate proposals to obtain MHSA funds. The total in county administrative costs is unexplored and unreported, but replicates state operations.
•MHSA state and county money supports legions of paid consultants and stakeholders, for conferences, committees, focus groups, and studies to "reinvent the wheel" and explore problems with known solutions. DMH reported that more than half of its budget was devoted to private contracts in the first years of implementation, but reports no longer include this detail. County advocates cannot easily determine how much money goes to overhead and how much is spent on direct services.
•The OAC approves county spending plans with no knowledge base of local conditions, and supports a public relations campaign to promote a celebration of MHSA "success," despite having no knowledge of MHSA benefits, and no comment on the critical MHSA implementation audit.
Consequences for Community Mental Health
Now, in 2010, implementation faces a double threat. To help plug the deficit, Governor Schwarzenegger's budget calls for shifting as much as $847 million from MHSA funds. Voters rejected a raid on Prop 63 funds in 2009, but the governor will try again in a June election, exploiting the incompetence or willful mismanagement of his own agents who have allowed county funds to pile up in a state account. He would eliminate system improvements because his administration lacks the capacity to efficiently fund them. After violating the original contract with voters, the governor will ask them to completely reverse the intent of the law. Strong voter support for community mental health has been consistent over decades--and underestimated by politicians. In July 2001, a professional survey showed a solid majority were aware of inadequate funding and in favor of an initiative; 67 percent said they had personal experience with people with a mental illness.
In an exchange of correspondence and newspaper opinion articles with DMH Director Dr. Stephen W. Mayberg, I challenged state policies calling for creation of new programs instead of higher standards for existing programs. Director Mayberg said the rationale for his plan is to prioritize services to "those most in need," and implied that this meant new clients identified through "outreach." He did not cite any research that determined a criteria for "most in need," did not explain why his purpose required new programs, nor why his private preferences should be honored above the provisions of the MHSA. There is no evidence to support DMH assertions that stakeholder participation influenced deviations from law.
Like many others who work for progress in mental health, my own perspective and acquired policy expertise started at home. When our three children were still in school, my husband died by suicide in Sacramento County as a result of untreated bipolar disorder. Since then, a second and third generation of my family members has sought treatment in public and private systems, and I have continued to advocate for promised services.
The waste of state revenue is inexcusable after decades of waiting for community mental health funding, and the magnitude of mismanagement, incompetence, and questionable expenditures is nothing less than scandalous. The numbers deprived of recovery are incalculable, and the numbers who despair and lose their lives are invisible.
My whistleblower complaint represents many in the mental health community who are opposing further waste of resources, and fighting to change the course of local funding. Thousands worked to pass the law and millions need its benefits. I believe a public demand for the integrity of the law--not the pretense of benefits marketed by some advocates--will ensure its success and the continued support of the electorate.
*Rose King is a political and policy consultant, and a family member of individuals with serious mental illness. As Chief of Staff to Lieutenant Governor Leo McCarthy, she initiated a state Task Force on Serious Mental Illness that developed landmark legislation in 1988. She worked with a drafting committee for Prop 63, and served as Principal Consultant to then-Attorney General Bill Lockyer to launch the MHSA Oversight and Accountability Commission during his tenure on the OAC in 2005-07. Rose has developed policy and communication strategies for state and national organizations and candidates, served California State Assembly and Senate leaders and Constitutional Officers, and the U.S. Congressional leadership since 1975. She has served numerous advocacy and civic organizations in her community and state.