BILL ANALYSIS
SENATE HEALTH AND HUMAN SERVICES
COMMITTEE ANALYSIS
Senator Martha M. Escutia, Chair
BILL NO: AB 34
A
AUTHOR: Steinberg and Baugh
B
AMENDED: August 16, 1999
HEARING DATE: August 18, 1999
3
FISCAL: Appropriations/Urgency
4
CONSULTANT:
McCarthy / ak
SUBJECT
Mental health funding: local grants
SUMMARY
Establishes new county demonstration programs, building
upon existing county programs serving adults who are
severely mentally ill, homeless, or recently released from
a correctional institution.
ABSTRACT
Current law:
1.Requires counties, as providers of last resort, to
support and provide needed health services to indigent
and incapacitated persons not eligible to be served by
other institutions or programs;
2.Requires the state Department of Mental Health (DMH) to
establish three county mental health care demonstration
projects under the Adult and Older Adult Mental Health
System-of-Care Act (hereinafter referred to as the "Adult
System-of-Care Act"). The Adult System-of-Care programs
provide community-based treatment, case management and
coordination of interagency services.
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This bill:
1.Requires DMH to administer a $10 million grant program to
demonstrate that comprehensive services can be provided
to severely mentally ill adults who are homeless,
recently released from a county jail or state prison, or
otherwise at risk of homelessness or incarceration.
2.Requires that, to be eligible for a grant, a county must
have an existing Adult-System-of-Care program or commit a
specified amount of new county funds to the demonstration
program.
3.Requires demonstration counties to enter a contractual
agreement with DMH to provide specified services.
4.Revises the Adult-System-of-Care Act statute to authorize
existing and expanded programs to add outreach and early
intervention as authorized program components as well as
authorizing other services.
5.Requires DMH to revise requirements for program
performance standards.
6.Requires DMH to expend $500,000 to measure (in
consultation with law enforcement, the Legislative
Analyst, and others) the cost of "comprehensive community
mental health care" and its impact on criminal justice
system expenditures associated with persons with mental
illness.
7.Requires the Department of Corrections to develop a
coordinated strategy of efficient, cost-effective
services to severely mentally ill parolees and authorizes
use of parole outpatient program funds to supplement the
mental health demonstration grant program.
FISCAL IMPACT
The State Budget Act, as signed by Governor Davis,
appropriates $10 million for the purposes of a
demonstration program serving persons who are homeless and
mentally ill. AB 34 is intended to provide the
programmatic structures for this demonstration program.
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This bill also states legislative intent to continue the
demonstration program if it is successful in treating
mental health patients and in "cost-effectively reducing
their hospitalization, incarcerations, and homelessness."
BACKGROUND AND DISCUSSION
1.Current law
Under Welfare and Institutions Code (WIC) Section 17000,
counties are the providers of last resort of income
support and health care to indigent and incapacitated
persons who are not supported and relieved by relatives,
friends, or public or private institutions or programs.
State policy changes, commencing in the 1970s,
transferred a number of mentally ill patients from state
mental hospitals to community-based treatment programs.
The policy of placing patients in community-based
programs was intended to improve the quality of life and
care of residents, and also was expected to reduce state
costs. In addition, as reiterated in a recent U.S.
Supreme Court Case (Olmstead vs. L.C. and E.W.), the
policy supported the right of mentally ill persons to
reside in the "least restrictive" environment possible.
The transfer has resulted in state cost savings,
according to the Mental Health Association of California:
"In the early 1970's, before significant
de-institutionalization, institutional care and state
mental hospitals represented 4% of the state general fund
budget. Budget cuts over the next 15 years, from 1975 to
1990,
reduced the percentage to about 1.5%." However, the
transfer resulted in additional fiscal pressure on local
government to provide services to mentally ill residents.
Under current state law, counties operate local
government mental health programs; however, funding
limitations result in few counties providing
comprehensive, integrated services to severely mentally
ill adults or significant outreach to homeless mentally
ill adults. According to the County Mental Health
Directors Association, despite the development of
community based system-of-care programs, "capacity
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remains inadequate. Community based services are
available to less than half those who need them. The
consequences of untreated, serious mental illness are
homelessness, police interaction, exacerbated symptoms
and other personal and community problems."
The Adult Systems-of-Care Act, AB 3777 (Wright), Chapter
982, Statutes of 1988, authorized demonstration programs
in three counties for delivering mental health services
to seriously mentally ill adults. Two types of
demonstration programs were authorized: a "system of
care" model, which has been piloted in Ventura County,
and an "integrated service agencies (ISA)" model, piloted
in Stanislaus and Los Angeles Counties. SB 659 (Wright),
Chapter 153, Statutes of 1996, reauthorized the
demonstration projects, and required DMH to issue
requests for proposals for additional projects in any
year in which funding was made available (WIC Section
5814). The Adult Systems-of-Care Act programs support
coordinated services from county and state agencies,
including criminal justice, mental health, employment,
housing, welfare, and health agencies. The Act also
requires DMH to establish standards for systems-of-care
programs, requiring: a county services plan;
consultation with specified local entities and families;
assignment of a case manager or multidisciplinary team
for each client; and an individual service plan for each
client.
2.AB 34 - Major Program changes
AB 34 makes substantive revisions to the Adult
System-of-Care Act and requires DMH to expand a few
existing programs through a new grant program. The
significant revisions to program requirements under the
Act are as follows:
a. Adds a new requirement that "outreach services" to
homeless mentally ill persons must be a program
component for both new and existing programs.
b. Revises the performance standards DMH must
establish for county programs to include outreach,
design of mental health services, access to
medication, substance abuse services, housing
assistance, veterans' services, and vocational
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rehabilitation.
c. Modifies performance standards to include county
sheriffs, local police chiefs and probation officers
among the local officials who must be consulted in the
operation of the system-of-care program.
d. Requires the criteria for program funding to
include development of a comprehensive plan for mental
health services to the target population, including
specified performance measures.
e. Expands requirements for individual case plans to
include goals of access to health care, reduction of
antisocial or criminal behavior, reduction of symptoms
of mental illness, living in the least restrictive
environment, engaging in work or other productive
activities, and access to vocational training.
f. Requires the DMH Director to grant award criteria
and performance measures for evaluating county
programs, including representatives from veterans'
services programs, law enforcement, mental health
providers, the Board of Corrections, substance abuse
service providers, the Department of Rehabilitation,
providers of employment services and several mental
health advocacy organizations.
g. Requires, beginning November 1, 2001, and annually
thereafter, that DMH report to the Legislature
regarding the impact of grants in reducing
incarceration of mentally ill persons and
recommendations on mental health policies.
3.Grant program expansion
AB 34 maintains as a first priority the funding of
existing programs that meet "adult systems of care
contract goals." AB 34 also continues the requirement
that, in any year in which additional funding is provided
in the State Budget for this purpose, DMH shall establish
additional demonstration programs. No local matching
funds would be required.
Counties receiving new demonstration grants would be
required to: provide data; agree to provide specified
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services; and specify the additional numbers of severely
mentally ill adults to whom the county will provide
comprehensive services. DMH would be required to select
counties that best demonstrate the county will
cost-effectively increase the number of mentally ill
adults served by June, 2001 and that can quantify both
funding needs and the impact of increased services.
4.Contract exemptions
AB 34 exempts the contracts entered into under the
revised system-of-care grant program from the Public
Contract Code, the State Administrative Manual and
approval by the Department of General Services.
5.County maintenance of effort
The new demonstration programs described in AB 34 would
be required to offer counties sufficient funds to
"comprehensively serve" severely mentally ill adults who
are homeless, mentally ill, recently released from county
jail or state prison or at significant risk of
homelessness and incarceration. For the new
demonstration programs, counties would have to assure the
demonstration funds provide new services and do not
supplant existing services.
6.Negotiations with Administration not yet
complete--further amendments possible
This Committee's first hearing on AB 34 was postponed
when the Governor struck the language the legislature
placed in the budget and indicated a desire to discuss an
alternative, more narrowly focused proposal. This bill,
as amended August 16, 1999, reflects agreements reached
in subsequent discussions with the Administration;
however, the Administration is finalizing an additional
set of amendments. It is anticipated by the author that
the pending amendments will not substantially modify the
current bill but may recognize a need to provide a
separate program for severely mentally ill persons with
long histories of criminal justice system involvement.
As of the date of this analysis, the specific provisions
of the pending amendments have not been released by the
Administration; presumably they will be available to the
Committee at the time of the hearing on August 18, 1999.
If they are not, the Committee may want to alert the
author that any substantive amendments may result in the
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Committee requesting the bill's return to the Committee.
In addition, substantive amendments may result in
significant changes in support or opposition.
7.Arguments in support of AB 34
This bill is sponsored by the Mental Health Association
in California. The author's purpose in proposing this
bill is to reduce homelessness of people with severe
mental illnesses. The author notes that, as such persons
frequently are unable to recognize the need for medical
assistance, a cycle of hospitalization, return to the
streets, arrest, and return to homelessness ensues.
The California Mental Health Planning Council argues this
bill will help reverse a pattern of underfunding that has
continued since deinstitutionalization of the mentally
ill in the early 1970's. The California Council of
Community Mental Health Agencies (CCCMHA) argues the only
way to stop the cycle of homelessness, due to untreated
illness, is to provide incentive funding for county
programs. The California Healthcare Association,
representing hospitals, argues: "Hospital providers are
acutely aware of the lack of appropriate treatment and
housing resources for the seriously mentally ill in the
community. It is often difficult, if not impossible, to
find appropriate aftercare services or residential
placement for a patient once he/she has been stabilized
in the hospital. With nowhere to go, patients often
relapse and either end up back in the hospital, or, too
often, in the criminal justice system".
In addition, the Little Hoover Commission, in support of
AB 34, states that in its 1998 report, Beyond Bars:
Correctional Reforms to Lower Prison Costs and Reduce
Crime, it found "?community based programs were a viable
alternative to prison for nonviolent offenders?" The
Commission states, "County services for the mentally ill,
such as AB 34, would constitute such a program." The
Commission argues counties bear all the cost of handling
offenders at the local level, but none of the cost when
judges send offenders to state prison and this "provides
a fiscal disincentive for counties to independently
develop alternatives, including expanded services to the
mentally ill."
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The California State Sheriff's Association states, in
support of AB 34, "?from a law enforcement perspective,
the need for adult mental health and related services is
clear. The unfortunate reality is that our local jails
have become the last resort for many of our mentally ill.
This is a disservice to them and to us". The Los
Angeles County Sheriff's Department asserts AB 34 will
add resources to keep mentally ill patients out of the
criminal justice system.
8.Concerns
a. The Citizens Commission on Human Rights, Church of
Scientology, has expressed concern regarding the
existing Ventura County demonstration project. The
expressed concern focuses on whether "blending" of
funds in that project resulted in uses other than that
for which they were appropriated, whether patients
were placed in the "least restrictive" environment,
and whether DMH exercised sufficient oversight.
Comment: The Committee may want to consider whether
the bill should be amended to require contracts
between DMH and a county to insure that: funds are
used for the purposes for which they are appropriated
or allocated; state and federal requirements regarding
tracking of funds are met; and patient records are
maintained in such a manner as to protect privacy and
confidentiality, as required under federal and state
law.
b. The County Mental Health Directors have taken a
support if amended position on the bill and have
requested the following amendments:
In the criteria to be used by DMH to select
counties for the new demonstration projects, delete
preference for counties currently receiving
"mentally ill offender crime reduction program"
funds [AB 34, WIC Section 5809.5(a)]. They argue
that, in general, the mentally ill offender crime
reduction program is targeted toward those with long
involvement with the criminal justice system -- a
different target population, both in nature and
duration of correctional system involvement.
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Eliminate the requirement that counties
competing for the new demonstration grant programs
must either have an existing adult systems of care
program serving the homeless mentally ill or that
the county appropriate county funds for the
treatment of "state parolees" [AB 34, WIC
5809.5(b)(2)]. They argue the counties should not
have to assume responsibility for state parolees.
The report to the Legislature required by this
bill should include, in addition to data on reduced
incarceration, the "impact of the programs on
reducing homelessness, reducing hospitalizations,
and improving work and community participation by
persons served" [AB 34, WIC Section 5814(e).]
PRIOR ACTIONS
Assembly Floor: 79-1Pass
Assembly Appropriations: 17-4Do Pass as Amended
Assembly Health: 14-0Do Pass as Amended
POSITIONS
Support: Mental Health Association in California
(sponsor)
Alta California Regional Center
American Federation of State, County &
Municipal Employees
American Nurses Association/California
Association for Los Angeles Deputy Sheriffs,
Inc.
Association of Regional Center Agencies
Board of Supervisors, counties of:
Contra Costa
Sacramento
San Francisco San
Mateo
Santa Clara Ventura
Butte County Behavioral Health Board
California Association of Social
Rehabilitation Agencies
California Association of Veteran Services
Agencies
California Catholic Conference
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California Church Impact
California Coalition for Mental Health
California Council of Community Mental
Health Agencies
California Correctional Peace Officers
Association
California Democratic Council
California Healthcare Association
California Independent Public Employees
Legislative Council
California Mental Health Planning Council
California Network of Mental Health Clients
California Nurses Association
California Probation, Parole and
Correctional Association
California Psychiatric Association
California Psychological Association
California State Association of Counties
California State Sheriff's Association
City of Sacramento
City of San Francisco
Congress of California Seniors
County Alcohol & Drug Program Administrators
Assn. of Calif.
County of San Joaquin Veterans Service
Office
County of Santa Clara Board of Supervisors
Department of Health & Human Services,
County of Marin
Department of Mental Health, County of Los
Angeles
Eli Lilly and Company
Engineers and Scientists of California
Families First
Family Service Council of California
Fresh Cut Florist and Gifts
Friends Committee on Legislation of
California
Governmental Advocates, Inc.
Jericho
Jewish Public Affairs Committee of
California
Jewish Community Relations Committee
Joann's Elegant Gifts
Johnson and Johnson
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Kern Regional Center
League of California Cities
League of Women Voters of California
Little Hoover Commission
Loaves and Fishes
Lutheran Office of Public Policy
Mental Health Association, counties of:
Los Angeles Orange
Mental Health Division of Contra Costa
County Health Services
National Alliance for the Mentally Ill,
chapters of
Los Angeles Marin
Ponoma Valley San
Bernardino
Sacramento San Diego
San Gabriel San Mateo
Tuolumne Ventura
Whittier
National Association of Social Workers,
California Chapter
Office of the Sheriff, counties of:
Amador Butte
Calaveras Contra Costa
Glenn Humboldt
Kern Kings
Los Angeles Marin
Mendocino Modoc
Monterey Napa
Nevada Orange
Placer San Benito
San Bernardino Santa Cruz
San Diego San Mateo
Santa Clara Shasta
Solano Sonoma
Stanislaus Tehama
Tuolumne Yolo
Yuba
Older Womens League of California
Orange County Coalition for Mental Health
Orange County Multi-Ethnic Behavioral Health
Servs. Task Force
Police Department, cities of:
Monrovia Sacramento
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Santa Barbara
Protection and Advocacy, Inc.
Regional Center of Orange Count
Sacramento County & Cities Board on
Homelessness
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SmithKline Beecham
Solano County Mental Health Board
Stanislaus Department of Aging and Veterans
Services
State Coalition of Probation Organizations
TACC Triple-A Council of California
Union of American Physicians and Dentists
Verdugo Mental Health Center
Veterans Service Office, County of San
Joaquin
Westside Regional Center
65 individual letters
SUPPORT California Mental Health Directors Association
(if amended)
OPPOSE: None received
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