Reversing California’s Slide : Model Mental Health Plan Seeks to Double Spending

Even if Gov. George Deukmejian gets the substantial boost in funding for the mentally ill that he has called for this year, state financial support for mental health will be less than it was before he took office.

That is one reason that Deukmejian’s highly touted mental health initiative does not satisfy critics of the state mental health system, who charge that programs remain woefully underfunded.

The increases would, however, help reverse a slide that began when Edmund G. Brown Jr. was governor and that was speeded along by Deukmejian when he vetoed $30 million for mental health in his first year in office.

“My impression is that the governor has been more interested, more committed, more involved in mental health than we’ve seen in a long time,” said John Ryan, Riverside County mental health director. “But I think there is still a reluctance to acknowledge the magnitude of the problem that exists out on the line. I don’t want to look a gift horse in the mouth, but it isn’t sufficient.”

Ryan recently asked the state Department of Mental Health to estimate the cost of funding what he and other health officials regard as a model mental health program for the state.

Dubbed the California Model, the proposal calls for developing in each county a full range of treatment services for the mentally ill--a spectrum that includes lolg-term care for the hopelessly ill and a range of treatment programs for others as they move from crisis to full recovery.

The plan--developed two years ago by a group that included legislative staff, county and state mental health officials, health professionals and patient and family organizations--spells out the minimum services that participants agreed every community ought to have to treat its mentally ill population.

For example, instead of the 2,200 hospital beds now in place in the public mental health system statewide for short-term care of patients in crisis, there would be 3,900. Instead of 1,800 beds for long-term rehabilitation, there would be more than 10,000.

The controversial plan would be costly.

Spending Would Double

Mental health spending would more than double from the $746 million budgeted for the current fiscal year to $1.8 billion if the California Model were now in place, according to the department’s estimates.

However, no one ever expected the proposal to be put into place overnight as written, said Henry S. Basayne, executive director of the state Mental Health Assn., the nonprofit group that directed the model plan workshops. Instead, it was intended as a goal for the state, he said.

But the Department of Mental Health has not endorsed the plan. “They have waffled,” Basayne said. State officials’ lack of enthusiasm “is like being in Alaska and not liking snow,” he said.

“We do support a system that is, in fact, a system,” said Dr. D. Michael O’Connor, state mental health director. And while he applauds the range of services recommended in the California Model, he argues that the proposal is not the only way to take care of the needs of the mentally ill.

Concerned About Cost

O’Connor is concerned about the cost and worried about imposing too many requirements on local government. “One of the real emphases of this Administration has to do with our attempt to transfer flexibility and control to local governments,” O’Connor said, “and not just (require) an array of services--so many of these (services) for so many of those patients.”

The governor, O’Connor added, is expressing “a real, sincere concern about people who are mentally ill in hospitals and in the community. And he wants to make a commitment to make the system better.”

The Administration is committed to spending more than $133 million over five years to upgrade state mental hospitals--a plan that could make California the first state to have all of its mental hospitals meet national standards.

But there has been no similar, specific commitment to upgrading community mental health programs in the long term.

A 30% Increase

The governor’s latest budget proposal does call for increases that would add significantly to mental health funding, bringing the total added since the 1983-84 budget to $160 million, an increase of 30%.

“If we can show the governor and the Legislature that there is an ongoing need there that is not being met, if we’re spending our money wisely and if the economy permits, we should expect a multi-year investment,” O’Connor said.

“Part of the mental health constituency raised so much hell that the governor decided he had to do something,” said Dr. John Richard Elpers, former director of mental health for Los Angeles County. “It will take a long time and many more restorations to get the program back to where we were in the mid-1970s. And we were not in good shape then.”

Elpers believes that the only way for mental health services to get their due is to establish a politically independent state authority to run the mental health system.

Need for Advocate

“What you need is a consistent, honest, credible organization to state the case (for mental health),” Elpers said. “That’s our dilemma. We don’t have it.

“I think O’Connor is in a very difficult position. I sat in the legislative budget hearings where he was asked whether he thought he had enough money to do the job. And I knew damn well he didn’t believe (he did), but he had to say it.”

Elpers and other county mental health directors have long complained that as increasing numbers of patients were released from state hospitals for treatment in local communities, the money did not follow them.

O’Connor calls that complaint “a massive overstatement and oversimplification.”

Says Money Did Follow

He said that as the number of people sent out of the state hospitals rose, the local money did increase. “Did all the dollars flow (to the communities)? Probably not. But many of them did,” O’Connor said. “And the fact of the matter is that if you look back to the 1960s and you were to ask me how many residential homes that treat the mentally ill were in place, there were hardly any. Today there are thousands.

“If you were to ask how many skilled nursing facilities (there are) in California that treat mentally ill--none. Now there are tens of thousands.”

In promoting its program, the Department of Mental Health likes to boast that California spends “more than any other state on local mental health programs.”

And that is true, primarily because California is the most populous state in the nation and spends a larger share of its state mental health dollars on community programs than any other state except Wisconsin, according to 1981 figures compiled by the National Assn. of State Mental Health Program Directors.

Population Factor

However, if California’s large population is taken ilto account, the state suffers by comparison with several others.

The association’s statistics, the most recent and most complete national comparisons available, show that California ranked 13th in per capita spending for both total mental health spending and spending on community health programs. The state slips to 41st among the 50 states on spending for state hospitals.

In 1981, New York spent $66.74 per capita for all of its programs, while California spent less than half that amount--$28.74.

Part of the reason may be that New York kept a large part of its mentally ill population in state hospitals, while California was closing its hospitals. Hospital care is the most expensive kind of treatment. Today it costs more than $50,000 per patient each year to maintain the state hospitals.

May Have Gone Too Far

But there is some feeling among health professionals that California simply went too far in clearing the wards of the state hospital system, on the expectation that patients could be cared for in less-restrictive settings.

“I’m a strong advocate of community care, but not to the degree I used to be,” psychiatrist Elpers said. “There can be no more reductions in state hospitals.”

O’Connor acknowledges that the state must provide hospitals for the most hopelessly ill patients, but he says there are better alternatives for the less seriously ill.

“If I added another 200 to 300 beds at Metropolitan State Hospital (in Norwalk), in a week they’d be filled,” O’Connor said. “I admit that. That doesn’t mean that’s appropriate. (It would cost) about $35 million a year. I bet if I had a group of county mental health directors and I said to them, ‘Look, I’ve got $35 million and you can either build a 250-bed hospital or you can do other things with it,’ they’d do other things with it.”

Assemblyman Bruce Bronzan (D-Fresno), who is proposing a major reform of the state’s mental health system, is still not convinced that the Administration will sustain a commitment to an improved system.

“It remains to be seen,” Bronzan said. Funding, he added, is “still way below what it should be and what it was. But at least it’s a forward movement instead of a considerable backward movement.”

PAYING FOR MENTAL HEALTH DIFFERENCES IN MENTAL HEALTH SPENDING BY COUNTY

1982-83 Amt. Per Rank County Allocation* Capita 1 Marin $6,003,801 $26.83 2 San Francisco 18,360,712 26.02 3 Mendocino 1,815,607 25.79 4 Sierra 79,452 23.93 5 Alpine 26,901 22.99 6 San Mateo 13,634,235 22.97 7 Napa 2,209,591 21.81 8 Colusa 295,460 20.81 9 Modoc 193,037 20.59 10 Mono 187,744 20.03 11 Inyo 363,660 19.55 12 San Joaquin 7,317,103 19.18 13 Trinity 238,509 18.78 14 Yolo 2,164,685 18.21 15 Alameda 19,926,269 17.97 16 Del Norte 327,788 17.62 17 Tehama 726,748 17.34 18 Mariposa 210,509 17.33 19 Sutter/Yuba 1,846,811 17.12 20 Glenn 385,824 17.11 21 Kings 1,299,715 16.35 22 Humboldt 1,783,352 16.04 23 Fresno 8,553,037 15.66 24 Santa Barbara 4,844,325 15.45 25 Calaveras 365,177 15.00 26 El Dorado 428,171 14.92 27 Merced 2,147,078 14.68 28 Santa Clara 19,337,195 14.40 29 Sacramento 11,832,840 14.09 30 Siskiyou 582,164 13.99 31 Butte 2,145,605 13.90 32 San Luis Obispo 2,346,502 13.79 33 California 332,165,935 13.31 34 Madera 938,308 13.23 35 Stanislaus 3,789,849 13.23 36 Tulare 3,323,091 12.64 37 Lassen/Plumas 531,610 12.60 38 Imperial 1,258,142 12.58 39 Los Angeles 96,365,076 12.52 40 Riverside 9,065,498 12.40 41 Contra Costa 7,908,946 11.60 42 Santa Cruz 2,296,075 11.46 43 Monterey 3,529,420 11.42 44 Placer 1,415,831 11.09 45 Amador 232,732 11.06 46 San Bernardino 10,552,950 10.70 47 Sonoma 3,364,945 10.58 48 San Diego 20,895,078 10.52 49 Solano 2,696,342 10.45 50 Tuolumne 386,181 10.41 51 Nevada 639,014 10.41 52 Lake 435,319 10.32 53 San Benito 280,029 10.13 54 Ventura 5,676,968 10.04 55 Shasta 1,221,559 9.93 56 Kern 4,162,026 9.40 57 Orange 16,738,160 8.22

* State Department of Mental Health figures