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For two years after Alfredo Ruiz was diagnosed with schizophrenia, his family tried -- and failed -- to find him help.
His mother knocked without success on the doors of shelters and medical clinics throughout the San Fernando Valley. Meanwhile, her son's illness sent him deeper into psychosis and paranoia. Unemployed and homeless, without access to treatment, he began sleeping under a bridge -- a knife under his body, just in case.
Today, Ruiz, 31, is stable and lucid -- and in the vanguard of a novel experiment in healthcare: Proposition 63, California's 1% surtax on incomes above $1 million that will generate $1.5 billion this fiscal year for treatment of the mentally ill.
Approved by voters in 2004, Proposition 63 aims to reform the long-troubled mental health system by finding and helping sick people who have historically had little access to care -- youths on the verge of homelessness, the elderly, poor minorities -- and severely ill adults who have fallen through the cracks. Proposition 63's authors hope the initiative will transform California's public mental health system, eventually creating a culture in which illness is no longer a patient's defining characteristic.
Ruiz is an early beneficiary of one of Proposition 63's main efforts, a style of therapy known as "whatever it takes" -- based on the notion that mental illness is rarely an isolated problem but is typically accompanied by physical illness, social isolation, educational deficiencies, poverty and other problems.
Now, instead of care that was patchwork at best, Ruiz is receiving comprehensive help from a team of more than a dozen clinicians.
In the past, if he had been lucky enough to score a spot in a shelter, Ruiz would have been handed an address and a bus token. Instead, his new caseworkers found him a place to live, drove him there -- and stopped to buy him a sleeping bag and toothbrush on the way. No longer overburdened by massive caseloads, they ferry him to appointments to ensure that he receives disability benefits. Not only do his case managers stop in weekly at his shelter to check on him, his psychiatrist visits too, to ensure that his pills are working -- a level of care that would have been a preposterous extravagance not long ago.
"They saved our lives," said Ruiz's mother, Maria Orduño.
But even as some have begun receiving platinum-level services unimaginable before Proposition 63 -- officials hope that 17,000 people statewide will be receiving "whatever it takes" therapy by next summer -- other kinds of care have deteriorated.
Some cash-strapped counties have slashed traditional funding for mental health services, and the state has made cuts too. In almost every corner of California, which has an estimated 1 million people with serious mental illness or emotional disturbance, core mental health budgets are stagnant at best while demand for services balloons.
Although mental health advocates in the state are thrilled about a guaranteed funding source that isn't subject to budgetary whims, they worry that innovative programs created with the new money are being layered on top of a disintegrating mental health system that Proposition 63 does nothing to correct.
And the new law forbids counties from using Proposition 63 money to backfill -- to pay for programs that existed prior to its passage. That provision was written to protect the new money, to keep counties from making cuts elsewhere that would undermine the promise of the new program. But it has also added to the sense among some healthcare administrators that their hands are tied.
"Proposition 63 was a huge policy mistake," said Jeff Smith, executive director of the Contra Costa Regional Medical Center, which cares for scores of poor, uninsured residents. "It took a good amount of money and dedicated it to new services at the same time that old services have been just ravaged. Instead of solving a problem, it just covered it over -- with a nice, fluffy frosting."
Early signs suggest that many counties -- as well as the state -- are cutting with one hand even as they are providing new, top-of-the line services with the other:
* Los Angeles County, which runs the nation's largest public mental health system, will receive more than $125 million in Proposition 63 money this year to fund an array of innovative programs. But at the same time, a $70-million shortfall in the county's core mental health budget has resulted in long waiting lists at many clinics. Some patients have had their number of visits with therapists cut in half; others no longer receive counseling at all.
* As part of a budget crisis, Santa Clara County recently ordered its Department of Mental Health to cut $17 million from its budget -- almost as much as the $19 million it will receive through Proposition 63 in 2007-08.
* Fresno County will use its $8.6 million in Proposition 63 funds to provide exhaustive care to 540 severely ill residents and for rural outreach, among other programs. But the county is simultaneously cutting about $8 million from the rest of its mental health budget. More than 140 of the county's 636 mental health staff positions have been eliminated, and the county will curtail services for about 650 clients with less severe conditions, such as depression and anxiety.
* Shasta County will receive $2.7 million in Proposition 63 money. But the new funding comes as the county has been forced to devote an increasing chunk of its mental health budget to expensive Medi-Cal cases -- leaving about $2 million less for standard patient care than before Proposition 63 began. The Health and Human Services Agency has laid off six of its nine psychologists. And the county now serves 500 fewer patients than before Proposition 63.
* In August, Gov. Arnold Schwarzenegger eliminated funding for a successful $55-million program for the homeless mentally ill -- the program that served as the model for Proposition 63. Advocates say the cut violates the new law, which specifically forbids the state from dropping below the funding commitment it had made to mental health before Proposition 63. Mental health advocates express conflicting feelings about the new law.
"The acknowledgment that mental health care is broader than medication and psychotherapy is brilliant. It's wonderful," said Marta McKenzie, director of the Shasta County Health and Human Services Agency. "But how do you build this new set of programs for a small population when you have this overwhelming set of responsibilities for this larger group of clients?"
His mother knocked without success on the doors of shelters and medical clinics throughout the San Fernando Valley. Meanwhile, her son's illness sent him deeper into psychosis and paranoia. Unemployed and homeless, without access to treatment, he began sleeping under a bridge -- a knife under his body, just in case.
Today, Ruiz, 31, is stable and lucid -- and in the vanguard of a novel experiment in healthcare: Proposition 63, California's 1% surtax on incomes above $1 million that will generate $1.5 billion this fiscal year for treatment of the mentally ill.
Approved by voters in 2004, Proposition 63 aims to reform the long-troubled mental health system by finding and helping sick people who have historically had little access to care -- youths on the verge of homelessness, the elderly, poor minorities -- and severely ill adults who have fallen through the cracks. Proposition 63's authors hope the initiative will transform California's public mental health system, eventually creating a culture in which illness is no longer a patient's defining characteristic.
Ruiz is an early beneficiary of one of Proposition 63's main efforts, a style of therapy known as "whatever it takes" -- based on the notion that mental illness is rarely an isolated problem but is typically accompanied by physical illness, social isolation, educational deficiencies, poverty and other problems.
Now, instead of care that was patchwork at best, Ruiz is receiving comprehensive help from a team of more than a dozen clinicians.
In the past, if he had been lucky enough to score a spot in a shelter, Ruiz would have been handed an address and a bus token. Instead, his new caseworkers found him a place to live, drove him there -- and stopped to buy him a sleeping bag and toothbrush on the way. No longer overburdened by massive caseloads, they ferry him to appointments to ensure that he receives disability benefits. Not only do his case managers stop in weekly at his shelter to check on him, his psychiatrist visits too, to ensure that his pills are working -- a level of care that would have been a preposterous extravagance not long ago.
"They saved our lives," said Ruiz's mother, Maria Orduño.
But even as some have begun receiving platinum-level services unimaginable before Proposition 63 -- officials hope that 17,000 people statewide will be receiving "whatever it takes" therapy by next summer -- other kinds of care have deteriorated.
Some cash-strapped counties have slashed traditional funding for mental health services, and the state has made cuts too. In almost every corner of California, which has an estimated 1 million people with serious mental illness or emotional disturbance, core mental health budgets are stagnant at best while demand for services balloons.
Although mental health advocates in the state are thrilled about a guaranteed funding source that isn't subject to budgetary whims, they worry that innovative programs created with the new money are being layered on top of a disintegrating mental health system that Proposition 63 does nothing to correct.
And the new law forbids counties from using Proposition 63 money to backfill -- to pay for programs that existed prior to its passage. That provision was written to protect the new money, to keep counties from making cuts elsewhere that would undermine the promise of the new program. But it has also added to the sense among some healthcare administrators that their hands are tied.
"Proposition 63 was a huge policy mistake," said Jeff Smith, executive director of the Contra Costa Regional Medical Center, which cares for scores of poor, uninsured residents. "It took a good amount of money and dedicated it to new services at the same time that old services have been just ravaged. Instead of solving a problem, it just covered it over -- with a nice, fluffy frosting."
Early signs suggest that many counties -- as well as the state -- are cutting with one hand even as they are providing new, top-of-the line services with the other:
* Los Angeles County, which runs the nation's largest public mental health system, will receive more than $125 million in Proposition 63 money this year to fund an array of innovative programs. But at the same time, a $70-million shortfall in the county's core mental health budget has resulted in long waiting lists at many clinics. Some patients have had their number of visits with therapists cut in half; others no longer receive counseling at all.
* As part of a budget crisis, Santa Clara County recently ordered its Department of Mental Health to cut $17 million from its budget -- almost as much as the $19 million it will receive through Proposition 63 in 2007-08.
* Fresno County will use its $8.6 million in Proposition 63 funds to provide exhaustive care to 540 severely ill residents and for rural outreach, among other programs. But the county is simultaneously cutting about $8 million from the rest of its mental health budget. More than 140 of the county's 636 mental health staff positions have been eliminated, and the county will curtail services for about 650 clients with less severe conditions, such as depression and anxiety.
* Shasta County will receive $2.7 million in Proposition 63 money. But the new funding comes as the county has been forced to devote an increasing chunk of its mental health budget to expensive Medi-Cal cases -- leaving about $2 million less for standard patient care than before Proposition 63 began. The Health and Human Services Agency has laid off six of its nine psychologists. And the county now serves 500 fewer patients than before Proposition 63.
* In August, Gov. Arnold Schwarzenegger eliminated funding for a successful $55-million program for the homeless mentally ill -- the program that served as the model for Proposition 63. Advocates say the cut violates the new law, which specifically forbids the state from dropping below the funding commitment it had made to mental health before Proposition 63. Mental health advocates express conflicting feelings about the new law.
"The acknowledgment that mental health care is broader than medication and psychotherapy is brilliant. It's wonderful," said Marta McKenzie, director of the Shasta County Health and Human Services Agency. "But how do you build this new set of programs for a small population when you have this overwhelming set of responsibilities for this larger group of clients?"
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