BILL ANALYSIS
AB 34
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Date of Hearing: April 6, 1999
ASSEMBLY COMMITTEE ON HEALTH
Martin Gallegos, Chair
AB 34 (Steinberg) - As Amended: April 5, 1999
SUBJECT : Mental Health Funding.
SUMMARY : Revises county mental health service standards to
include access to integrated services, and establishes fiscal
incentives for counties to engage in outreach to mentally ill
persons. Specifically, this bill :
1) Revises county mental health service standards to be
developed by the Department of Mental Health (DMH), to
include coordination and access to medication, substance
abuse services, housing assistance, and vocational
rehabilitation services. Includes goals helping clients to
attain the most independent, least restrictive housing, and
to self-manage illnesses.
2) Requires, as funds become available, the three existing
demonstration projects established in the Adult and Older
Adult Mental Health System of Care Act to be expanded to
counties with significant populations of homeless mentally
ill persons.
3) Establishes four-year planning and expansion grants to
counties, and provides for increased funding reflecting
increases in the number of mentally ill adults who receive
mental health services for at least four consecutive months.
4) Requires expansion grants to be sufficient to provide mental
health services, medically necessary medications, alcohol and
drug services, housing assistance, vocational rehabilitation,
financial management assistance and stipends to attract and
retain sufficient numbers of qualified professionals to
provide necessary levels of services.
5) Permits an expansion grant to be renewed if the county
demonstrates to DMH that the services are successfully
reducing mental health needs and reducing law enforcement,
criminal justice system, and state corrections expenditures
spent on severely mentally ill persons.
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6) Permits grant reductions based upon benchmarks for a 20% or
larger reduction in incarceration rates over the four-year
grant. Permits a county's contract to specify a different
measure if there are circumstances making it difficult for
that county to obtain a 20% reduction. Permits DMH to
approve grant renewal if the benchmark is unmet and the
county is stabilizing more mentally ill and reducing
homelessness, and achieving the maximum feasible reduction in
incarceration of mentally ill persons.
7) Permits subsequent funding to be limited, or for conditions
for improvement to be imposed upon a county that received a
grant, but did not reduce criminal justice expenditures as a
result. Requires appropriations in this bill to be reduced
by the amount that the Director of DMH determines is not
required to fully fund grants due to the failure of counties
to adequately reduce incarceration.
8) Requires, beginning in 2004-2005, the Director to report to
the Legislature about the impact of grants in reducing
incarceration of severely mentally ill persons.
9) Appropriates $3 million from the General Fund during the
current (1999-2000) fiscal year to DMH. Requires $500,000 to
be allocated for training, $500,000 to be allocated for
homeless outreach training for counties, to be offered
through an organization with significant success with
homeless outreach programs. Requires $2 million to be
allocated for county planning grants.
10)Appropriates General Fund moneys to DMH as follows:
a) $50 million for the 2000-2001 fiscal year;
b) A sum not to exceed $100 million for the 2001-2002
fiscal year;
c) A sum not to exceed $150 million for the 2002-2003
fiscal year;
d) A sum not to exceed $200 million for the 2003-2004
fiscal year;
e) A sum not to exceed $250 million for the 2004-2005
fiscal year;
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f) A sum not to exceed $300 million for the 2005-2006
fiscal year; and
g) A sum not to exceed $350 million for the 2006-2007
fiscal year.
11)Requires that if the Director determines that funding is
inadequate, funding in the 2007-2008 and subsequent years may
be increased by up to $50 million per year, and prohibits
total appropriations for this purpose from exceeding $500
million in any one year.
EXISTING LAW :
1) Requires counties to relieve and support incompetent, poor,
indigent persons, and those incapacitated by age, disease, or
accident, when such persons are not supported and relieved by
relatives, friends, or other public or private institutions.
2) Establishes a target client population for county mental
health services that includes severely mentally ill adults,
and children with severe emotional disturbances. The adult
target population is further defined to be restricted to
those with functional impairment in independent living,
social relationship, vocational skills, or physical condition
and to meet other specified criteria. The target population
includes homeless mentally ill persons, persons requiring
acute inpatient psychiatric care, persons arrested or
convicted of crimes, and those with symptoms of psychosis,
suicidality, or violence.
3) Establishes three mental health care demonstration projects
in the Adult and Older Adult Mental Health System of Care
Act, and declares that mentally disordered adults should have
an interagency network of services with multiple points of
access.
4) Requires DMH to issue requests for proposals to develop
system of care programs no later than October 1 in any year
in which the state budget provides new funds to expand the
system of care provided for in the System of Care Act.
FISCAL EFFECT : $3 million in General Fund appropriations in
the 1999-2000 fiscal year. Annual General Fund appropriations
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beginning with $50 million in 2000-2001, and potentially
increasing in $50 million increments up to appropriations of
$500 million annually.
COMMENTS :
1) PURPOSE OF THIS BILL . The author is proposing this bill to
reduce homelessness of people with severe mental illnesses,
and to provide counties with incentive funds for that
purpose. The author notes that the severely mentally ill,
especially those with schizophrenia and bipolar disorder,
frequently become completely disoriented and are not able to
recognize or accept the need for medical assistance. When
medical attention is not sought, the condition worsens, and a
cycle of emergency hospitalization, return to the streets,
arrest, incarceration and return to homelessness ensues. The
author argues that since their homelessness is due to
biological illness over which they have no control, the
mentally ill are often the most vulnerable and helpless
members of society, and need government intervention and
assistance to restore their health and independence.
Additionally, by the time someone is homeless, a mentally ill
person may need a range of services relating to housing,
chemical dependency, and vocational rehabilitation. The
author asserts that counties and community agencies lack
sufficient resources to reach out to more afflicted persons
and serve them adequately. This bill is sponsored by the
Mental Health Association in California.
2) PRIOR LEGISLATION . AB 3777 (Wright), Chapter 982, Statutes
of 1988, authorized two types of pilot programs for
delivering mental health services to seriously mentally ill
adults and older adults: a system of care model, which has
been piloted in Ventura County, and the integrated service
agencies (ISA) model, piloted in Stanislaus and Los Angeles
Counties. The focus of these programs has been to help
clients reach functional status through access to coordinated
services to address multiple problems that tend to be
concurrent, such as mental illness, substance abuse and
homelessness. According to the sponsor, these programs have
been successful in reducing average length of hospital stays,
improving access to physical health care, minimizing
incarceration and increasing the percentage of participants
who are able to live independently.
3) SB 659 (Wright), Chapter 153, Statutes of 1996, reauthorized
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the three demonstration projects, required DMH to issue
requests for proposals for additional projects in any year in
which the state budget provides additional funds for that
purpose, and required participating counties to develop
interagency program outcomes and goals. Funding to expand
beyond these demonstration projects has not been provided.
4) SUPPORT . The California Council of Community Mental Health
Agencies (CCCMHA) argues that the only way to stop the cycle
of homelessness due to untreated mental illness is to provide
incentive funding for county mental health programs to
provide the comprehensive integrated services to get people
off the streets and into effective programs. CCCMHA asserts
that a client-centered, ISA model, which offers an array of
services through a multidisciplinary team would keep people
out of the hospital and allow most to work and live
independently. The California Mental Health Directors
Association (CMHDA) states that this bill provides a
desperately needed expansion of community services in a way
that recognizes the highest quality in community services,
and targets expansion to the neediest persons who are
homeless or at risk of homelessness. The California
Psychiatric Association (CPA) notes that adults with severe
mental illnesses do not receive adequate care, and thus end
up in jails and prisons. CPA concludes that current policies
and funding levels send the message that "if you want mental
health care, get arrested," since the level of care in
prisons and jails is generally much better than any available
outside those institutions. The Los Angeles County Sheriff's
Department indicates that its jail system runs the largest
mental health facility in the nation, providing mental health
services for over 2,400 inmates each day. The Sheriff's
Department believes this bill will provide necessary
resources to keep mentally ill patients from committing
crimes and unnecessarily weighing down our criminal justice
system. The California Mental Health Planning Council argues
that this bill will help reverse a pattern of serious
underfunding that has continued since deinstitutionalization
of the mentally ill began in the early 1970's.
5) SUPPORT IF AMENDED . The California Probation, Parole and
Correctional Association (CPPCA) supports this bill in
concept, but is requesting an amendment to include probation
departments as entities eligible, either on their own or in a
joint application with county mental health departments, to
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receive grant funds. While the California Healthcare
Association (CHA) strongly supports the policies outlined in
this bill, CHA expressed concerns with a previous version of
this bill, which earmarked tobacco settlement funds for this
purpose. Recent amendments to this bill deleted all
references to the tobacco settlement, and therefore may
address CHA concerns.
6) MEDI-CAL MANAGED CARE . As the sponsor notes, the federal
government has entered into capitated payment arrangements to
provide Medicaid (referred to as Medi-Cal in California)
matching funds to states based upon their historical amount
of federal funds drawn. Other states, such as Utah and North
Carolina, have received more than double the amount
California would receive under a similar arrangement. While
California has been implementing a managed care model for
mental health services provided through Medi-Cal, this bill
intends to increase county mental health funding provided by
the state by implementing payment by case rate. It is
unclear how existing efforts to implement mental health
managed care would be impacted by the requirements of this
bill.
7) FLEXIBLE BENCHMARKS . In an effort to ensure that this bill
achieves its aims of serving more mentally ill persons and
reducing incarceration rates, the author has recently amended
this bill to require benchmarks for counties to reduce
incarceration rates by 20% over a four-year grant period.
However, an individual county contract may specify a
different measure if there are known circumstances making it
difficult for that county to obtain a 20% reduction. Under
this provision, any county might reasonably argue that there
are circumstances making it difficult to reduce incarceration
by 20%. It is unclear how restrictive or attainable this
benchmark would be.
REGISTERED SUPPORT / OPPOSITION :
Support
Mental Health Association in California (sponsor)
Alliance for Community Care
American Federation of State County and Municipal Employees
Association of Community Mental Health Agencies
California Coalition for Mental Health
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California Council of Community Mental Health Agencies
California Healthcare Association (if amended)
California Independent Public Employees Legislative Council
California Mental Health Directors Association
California Mental Health Planning Council
California Network of Mental Health Clients
California Nurses Association
California Probation, Parole and Correctional Association (if
amended)
California Psychiatric Association
California Psychological Association
California State Sheriff's Association
County of Sacramento
Family Service Council of California
Friends Committee on Legislation in California
Los Angeles County Sheriff's Department
Mental Health Association of Orange County
National Alliance for the Mentally Ill, Sacramento
Older Women's League of California
Orange County Multi-Ethnic Behavioral Health Services Task Force
San Diego Alliance for the Mentally Ill
San Gabriel Valley Alliance for the Mentally Ill
Several individuals
SmithKline Beecham
Union of American Physicians and Dentists
Opposition
None on file
Analysis Prepared by : Ann Blackwood / HEALTH / (916) 319-2097