Officials Hopeful Trial Will Boost Mental Health Funding

A lawsuit that pits California counties against each other in the competition for state dollars is wrapping up in San Diego County Superior Court, a milestone in the county’s long dispute over mental health funding.

A January ruling in part of the case--saying that the state unfairly and illegally allocated funds at least since 1986--has led to quiet optimism among San Diego County officials about the case’s final outcome.

So, too, has the judge’s refusal to be diverted from what San Diego considers the crux of its case: whether state funding decisions on mental health have been rational.

Judge Barbara Gamer “was very clear in her thinking, and didn’t let other people confuse her with additional stuff that was irrelevant,” said county mental health director Areta Crowell. “She excluded all kinds of stuff that the other side tried to bring in.”

The lead San Diego attorney, Michael B. Poynor, said he is hopeful that the judge will agree that the state had made a long series of irrational policy decisions that favored some counties and hurt others.

“The result is a luxury class of county and a poverty class of county,” he said.

Gamer asked attorneys on both sides to present written summaries to her by last Friday, and reply briefs by the end of this week. She will have 90 days after that to make her ruling, but some of the attorneys expect that it could come within a month.

The first phase of the trial occurred in the fall, and the second extended over three weeks beginning Jan. 28.

When San Diego County sued in 1986, it was alone in taking comprehensive action to remedy below-average state support for county-run mental illness programs for the poor and the uninsured.

But by the time it was heard, the case had mushroomed into a confrontation between the haves and the have-nots of mental health in California.

Six counties joined San Diego in challenging the status quo. Nine other counties opposed them, saying it would be unfair to gut their mental health programs just to achieve equity elsewhere.

“To take away from one mentally ill patient to give to another is not rational,” said Brenda Carlson, attorney for San Mateo County in the case. “If you take away more from us, the programs are just going to collapse.”

It wasn’t a confrontation that mental health directors enjoyed, Crowell noted. They had long debated the unequal funding issue at meetings of the California Conference of Local Mental Health Directors, she said.

“People got so tired of talking about equity, and had such a hard time reaching agreement in a political arena, that it was at one time jokingly banned from the agenda,” she said.

It became even clearer during the trial that the state Department of Mental Health will never move aggressively to settle the dispute, because of political pressures, said Howard K. Watkins, senior deputy county counsel for Fresno County in the case.

“I’m more convinced now than I was at the start of the case that if there’s going to be equity in mental-health funding amongst the counties, it’s going to take a court order to accomplish it,” Watkins said. “If you had a leader that did that, politically he would not last.”

The key to San Diego County’s case against the state is whether there is a rational basis for the wide disparity between counties at the top of the mental health funding ladder and those at the bottom.

On average, the state gives counties $26.45 per county resident per year toward its mental health programs, Poyner told the court.

But San Diego County receives $19.38, putting it near the bottom of the state’s 58 counties in such funding. Furthermore, some other counties receive much more than the state average: for instance, $54.42 in San Francisco, $44 in San Mateo, and $52.22 in Marin. In Los Angeles, the figure is $28.86. (All these figures are weighted to account for differing numbers of poor people in the various counties.)

San Diego and its allied counties say there is no rational basis for those differences. The state and the nine counties siding with it contend that the differences are the legacy of decisions that individual counties made in the 1960s and 1970s.

Furthermore, they say the state must balance two competing objectives: maintaining existing programs and trying to raise allocations for underfunded counties.

But a top Department of Mental Health official, Douglas G. Arnold, acknowledged during the trial that, at the current rate of change, it would take 50 to 100 years to smooth out the differences.

“How many people are born, develop schizophrenia in their 20s, and then go untreated in that time?” Poynor asked. “To have generations of people come and go while the state plays catch-up is totally intolerable.”

In her ruling in the statutory phase of the case, issued Jan. 10, Gamer agreed with San Diego that the state had failed to comply with state laws requiring it to have a clear and reasonable plan for remedying inequity in mental health funding.

Gamer noted that the state official in charge of allocations to county mental health programs, Leland Tom, had testified that he didn’t know what progress toward equity had been made since 1986.

“In fact, he had no idea what progress toward equity meant,” Gamer wrote.

Likewise, the Department of Mental Health could not support its use of a formula for funding counties based on their population of poor people.

“Mr. Tom testified (that) only one man understood how the poverty-population formula works and he is no longer with the department,” she said.

The state’s refusal to place specific San Diego County patients in state institutions for care also violated the patients’ civil rights, she said.

Gamer ordered that the state adopt allocation regulations consistent with her ruling by July 1, 1992; that the state make “reasonable” progress toward equity with all future allocations, and that the Legislature be kept apprised of progress annually.

Those orders presumably would result in a regulatory structure that would progress toward equity more quickly than the 100-year timetable Arnold estimated.

But San Diego and its allied counties are hoping for a faster remedy on constitutional grounds, the phase of the case that is being completed now. The question is: Is it unconstitutional for the state to fund a system in such a way that it gives better care to the mentally ill in one county than another?

“We want the system declared unconstitutional,” Poynor said. “I think the state of California has built itself a financial Frankenstein, a monster that is totally out of control.”

The county’s mental health director says that, even if San Diego and the other counties don’t win the constitutional phase of the case, they already have gained ground because of the suit.

“Quite apart from whatever comes out of the rulings, we have started to see the department behave differently than they had in the previous 10 years,” Crowell said. “So I keep reminding people that the board (of supervisors) has made a tremendous investment and it’s paid off already.”

MENTAL HEALTH FUNDING

These are per-capita figures for mental health funding that selected California counties are receiving in 1990-91.

County Per Capita Tulare $17.12 Fresno $17.18 San Bernardino $18.36 Imperial $19.15 SAN DIEGO $19.38 Stanislaus $20.11 Riverside $24.14 State Average $26.45 Mendocino $27.90 Los Angeles $28.86 Alameda $30.32 Contra Costa $30.39 Solano $31.33 San Mateo $44.29 Napa $52.00 Marin $52.22 San Francisco $54.42

Source: Trial exhibit submitted by San Diego County, based on California Department of Health Services data.