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Can a $6.4 billion mental health ballot measure solve California homelessness?

San Jose Mercury News - 2/11/2024

For decades, thousands of Californians struggling with mental health and addiction have languished on the street. Now, voters will decide whether a March 5 ballot measure is the solution to get them the care they desperately need.

Proposition 1, the only statewide measure on the ballot, would raise almost $6.4 billion in bonds for more than 11,000 new treatment beds and homeless housing units. The two-part measure would also use money already in the mental health system to expand intensive care programs and build supportive housing, potentially leaving fewer funds for early intervention or other services. It would do both without raising taxes.

Backers of Proposition 1 acknowledge it would help only a fraction of California’s estimated 181,000 unhoused residents. But they say the measure largely targets homeless people with the highest needs — the ones voters are most likely to see wandering into traffic or yelling at no one.

While disability rights advocates and some local officials have raised concerns about the prospect of more involuntary detentions and changes to mental health funding, Proposition 1 has broad support from both Republican and Democrat state lawmakers, who’ve sent the measure to voters amid increasing public pressure to get a handle on homelessness. They describe Proposition 1 as the linchpin of an ongoing mental health overhaul aimed at compelling more people with severe psychiatric disorders into treatment.

“We’ve created more flexibility, more tools, more accountability, more resources,” said Gov. Gavin Newsom. “Now, we need more beds.”

What would Prop. 1 do, exactly?

The measure would allow the state to issue $6.38 billion in bonds to add an estimated 6,800 beds for people needing mental health care or addiction treatment in hopes of making up for a bed shortage that also extends nationwide. Including state hospitals, California currently has an estimated 21,000 psychiatric beds. Prop. 1 would also fund around 4,350 homeless housing units, with about 2,350 set aside for homeless veterans.

Counties could use the money to build or expand a range of treatment centers, from long-term residential care facilities for those in more stable condition to locked-door clinics for those in crisis. New housing projects would have on-site services to connect residents with mental health care or drug counseling.

Although the added mental health beds would not be specifically for homeless people, the overarching goal is to help those with the most serious disorders and disabilities, who often end up on the street.

According to a UC San Francisco survey of homeless people across the state last year, more than two-thirds said they were experiencing mental health symptoms.

Still, experts say people with severe conditions make up a minority of the unhoused population, making clear the state must also continue investing in housing if it hopes to end homelessness.

“This conversation is focused on a very small subset because those folks become the most visible when they’re outside,” said Ray Bramson, chief operating officer of Destination: Home, a Silicon Valley homelessness solutions nonprofit.

The bond money would be distributed through project grants, for which counties would apply. The bonds would cost the state an estimated $310 million annually over 30 years, less than half a percent of its expected general fund revenue, according to a Legislative Analyst’s Office report.

Proposition 1 would also require counties to spend 30% of the cash they receive from the voter-approved Mental Health Services Act — a state tax on millionaires — on rental assistance and supportive housing construction, including for homeless people. The mental health tax raises roughly $1 billion each year.

Additionally, counties would have to spend 35% of those funds on people with the most critical needs. For some counties, that could mean shifting money away from programs to help those with milder symptoms. The measure would also redirect about $140 million each year from counties to bolster state mental health programs.

What else is the state doing to overhaul its strained mental health system?

Proposition 1 backers blame the shuttering of many of California’s massive psychiatric hospitals starting in the 1960s for the overburdened mental health system it has today.

The closures were part of a statewide movement to “deinstitutionalize” people with mental health issues and other disabilities. That effort culminated with then-Gov. Ronald Reagan signing the Lanterman-Petris-Short Act, which strictly limits when people can be involuntarily committed.

The state now has a shortage of roughly 7,730 treatment and residential care beds, according to a 2021 study from the public policy think tank RAND. That’s about 1,000 more than Proposition 1 promises to create.

Even so, Oakland Mayor Sheng Thao said adding beds would ensure local officials are successful in “bringing in those who can’t make decisions for themselves, because of whatever situation that they are in, and giving them an opportunity to live out their life in a dignified way.”

To compel more homeless people into treatment, Proposition 1 backers point to two recent reforms being phased in across the state.

The first is CARE Court, a new program allowing health care professionals, family members and others to petition judges to order some homeless people into mental health programs. The second is a state law that went into effect this year changing conservatorship rules to force more homeless people unable to provide for their basic needs into involuntary care.

What are the arguments against Prop. 1?

Disability rights groups argue the measure and accompanying mental health reforms represent a potentially dangerous regression to the inhumane forced treatment of the past.

Some taxpayer groups say issuing new bonds would inevitably lead to wasteful spending and burden the state with more unsustainable debt as it’s already struggling to balance its budget.

At the same time, local officials worry the changes to the Mental Health Services Act funding could force cuts to some existing county mental health programs and staff.

Susan Ellenberg, president of the Santa Clara County Board of Supervisors, is worried less money for programs to treat residents’ mental health disorders before they become serious could hamper the county’s effort to prevent homelessness. She also said the changes would require the county to give up $9 million to support state-run programs.

Who supports the measure?

Proposition 1 has won support from various business, labor, construction and health care groups, including the Service Employees International Union and Kaiser Permanente. As of Jan. 24, backers had reported raising more than $16 million in campaign contributions, while opponents had collected just $1,000.

The measure appears to have the early support of voters, with 68% in favor, according to a December poll by the Public Policy Institute of California. Proposition 1 needs a simple majority to pass.

Alison Monroe, of Alameda County Families Advocating for the Seriously Mentally Ill, said the measure might have saved Diana Staros, whom she took care of as a teenager, from overdosing in an East Oakland laundromat last year at the age of 28.

Staros was living at a residential care home in Oakland when she died. Monroe believes Staros needed more intensive treatment for schizophrenia in a locked-door facility, but she said few such options were available in Alameda County.

“She probably would not have favored that at all and said that she’s being locked up,” Monroe said, “but at least she’d be alive.”

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