Mental Health Programs May Be on Road to Recovery : Medicine: A realignment plan shifts responsibilities to the counties and guarantees a stable source of income. The governor had pushed for the plan.

After years of budget cuts and neglect, California mental health programs may be on the road to recovery.

While some question how long a recovery would take, officials are predicting significant improvements as the result of a landmark “realignment” of mental health services. It not only shifts responsibility of these programs to counties, but, for the first time, guarantees a stable source of income.

State spending for mental health had dropped from 4% to less than 2% of the General Fund in the last 25 years. Spending was either frozen or cut every year during the 1980s. Meanwhile, the state’s population soared, as have the numbers of mentally ill.

The results were predictable. The mentally ill are filling the jails and are spilling onto the streets of the state’s largest cities. Treatment centers like County-USC Medical Center in Los Angeles are overwhelmed by hordes of severely disturbed people. Patients move through a “revolving door,” from state hospitals to community-based treatment programs and back to state hospitals, often without receiving the care they need.

“This is the greatest failure of domestic policy in our state, probably in our nation,” said Assemblyman Bruce Bronzan (D-Fresno), who has fought for better mental care for years. “It is a true calamity.”

The realignment plan shifts $2.2 billion of health and social services from the state to California’s 58 counties. About $700,000 will be spent on mental health in the first year and more in subsequent years from the proceeds of a half-cent sales tax increase and higher vehicle license fees. Much of the money will be placed in county “trust funds,” earmarked for mental health.

Legislation calling for the shift was sought by Gov. Pete Wilson and supported by mental health advocacy groups.

Although the overall state budget process is stalled, this will not affect the new mental health plan, state officials said.

“This particular piece (of the budget) is settled,” said Diane Cummins, manager of health and welfare programs for the state Department of Finance. “The governor has signed the realignment bill and he has also signed the sales tax and vehicle license fee bills. They are now state law.”

The state yields most decision-making authority to the counties. But state officials will insist that counties follow certain guidelines and require the counties to prove they are using the money to good effect. For the first time in at least 20 years, money for mental health programs will be protected from being raided for other purposes, a problem for decades.

Dr. William Mayer, the state’s new director of mental health, predicted in a recent interview that the reorganization of mental health services along with development of new drugs and other new medical procedures and a lessening of the stigma attached to mental illness could combine to lead California into a “new age of enlightenment.”

That would be a welcome change from today’s chaos.

Nobody knows how many seriously mentally ill people live in California. But Dan Weisburd, president of the California Alliance for the Mentally Ill, a family support group, said a conservative number is about 500,000. Perhaps half of those are receiving treatment, he said.

Sandra Goodwin, consultant to the Assembly Health Committee, said there are at least 40,000 mentally ill homeless people in the state.

At County-USC Medical Center, she said, “the police bring in the most serious cases and they are placed on mats on the emergency room floor until there is no more room and then the door is closed.”

This also happens at other Los Angeles County hospitals: Harbor General-UCLA Medical Center, Olive View and Martin Luther King Jr./Drew Medical Center, said Fran Dowling, acting mental health director for Los Angeles County.

Some of the acute cases that are turned away go to outpatient “crisis units,” Dowling said, but many “wind up back on the streets and get into trouble again.”

And many go to jail.

“The Los Angeles County jail is the largest psychiatric institution in the United States,” Goodwin said.

Obtaining proper medical treatment for their mentally ill children is another nightmare for parents. Many families run through their personal savings quickly, then are dependent on inadequate Medi-Cal payments.

Don Richardson, a retired Los Angeles school administrator with two schizophrenic sons, said he had spent all of his $58,000 in savings when one of the boys required a liver specialist. Richardson spent weeks talking to specialists before finding one who would accept the low Medi-Cal payment.

Dan Weisburd’s 30-year-old son, a paranoid schizophrenic, walked seven miles to the UCLA Neuropsychiatric Institute and Hospital because, his father said, “he felt he was coming apart.”

UCLA did not treat him because it no longer accepts Medi-Cal payments, Weisburd said, but it did later present a bill for $185 for outpatient services.

“Those are the anomalies you face,” he said. “They talk about people falling through the cracks. This system is all cracks.”

The decline in California mental health care began in the late 1960s and early ‘70s, after new drugs that could control all but the worst behavior came onto the scene. At the same time there was a growing belief that too many people were being locked away in state hospitals.

The Administration of then-Gov. Ronald Reagan seized upon these developments to make sharp cuts in the mental health budget. Thousands of patients were released from state hospitals to community-based mental health facilities. The number of mental patients in state hospitals has dropped from 37,500 in 1958 to about 5,000 today.

“What they intended was very humane,” Goodwin said, but, unfortunately, an adequate supply of money did not accompany the patients to community facilities and a treatment gap began to grow that now has become a chasm.

Growing concern for the civil rights of mental patients compounded the problem, in the opinion of some legislators and mental health officials.

“Most of the time, we can’t force people into treatment,” said Mayer, the state’s new mental health director. “That leaves a a lot of helpless sick people out there.”

Mental health programs languished during recent administrations.

“The last three governors (Republicans Reagan and George Deukmejian and Democrat Edmund G. Brown Jr.) have not been very friendly to mental health,” Bronzan said. “Deukmejian showed a total lack of interest.”

Wilson has been a refreshing change, people working in the field say.

“The governor has been the point man for significant change,” said Weisburd of the mental health alliance. “He grasps the enormity of the problem.”

Gayle Wilson, the governor’s wife, has taken a personal interest since a close friend, suffering from schizophrenia, committed suicide several years ago. She later worked as a volunteer in a mental hospital and “to a certain extent has been the governor’s eyes and ears on this issue,” said Bill Livingstone, Wilson’s press secretary.

From the start of this year’s budget negotiations, Wilson “made it clear he wanted to protect mental health funding,” despite facing a budget deficit that eventually grew to more than $14 billion, Goodwin of the Assembly Health Committee said.

As the army of the mentally ill has grown, and has become a nuisance if not a menace, on the streets, the public has paid more attention to the problem, Bronzan said.

In addition, the Fresno legislator said, “the politics have changed since the parents got involved in a major way.” He referred to the California Alliance for the Mentally Ill, whose 71 local chapters have pressured legislators and local officials to increase spending and improve care for the mentally sick.

“They’re incredibly knowledgeable and they’ve learned all the things that don’t work,” Bronzan said.

As Bronzan and other legislators talked to the new Wilson health team, the realignment concept began to take shape.

First, they had to find a way to protect mental health budgets from the regular assaults of governors and legislatures. “This was absolutely the most vulnerable program” in the health and welfare budget, said Theresa A. Parker, undersecretary of Health and Welfare.

The solution was to dedicate part of the revenue from a half-cent sales tax increase, and from higher vehicle license fees, to the 58 counties for mental health programs--altogether $700 million for the first year and more in later years.

The money is to be placed in a special trust fund in each county, both to guarantee that the money is spent for mental health and not for other purposes, and to insulate the funds from the demands of Proposition 98.

If the revenue flowed into a county’s general fund, instead of a special trust fund, at least 40% of it would have to go to schools, under terms of the 1988 voter-approved initiative that assures a minimum funding level for public schools and community colleges.

If revenue from the sales tax increase and from higher vehicle license fees comes in as anticipated, mental health programs not only will have a stable funding source for the first time but also should rise by an expected 7% or 8% a year.

Counties not only will have more money to spend but also greater flexibility to spend it.

“We’re saying we (the state) are the provider, the county is the purchaser and it’s up to them to decide (on what mental programs) to spend the money,” Parker said.

Each county will sign a contract with the state, specifying how much money is to be spent on state hospital beds, how much for community-based facilities and how much for “institutes for mental disease,” which are nursing homes for the mentally ill.

“This brings the decision-making process to the local area, where we think it ought to be,” said Fran Dowling of Los Angeles County.

Dowling cited as examples of local initiatives a Skid Row walk-in clinic and the Corporate Cookie, a mid-Wilshire store where recovering mental patients serve up cookies, yogurt and soft drinks.

But there will be state guidelines, including a requirement that counties spend most of their money on the sickest patients and adopt “outcome measures” to determine how effectively the money is being spent.

Transferring mental health authority will not solve all of the problems.

For one thing, mental health programs have been so decimated that it will take a long, painful effort to restore them to mere adequacy.

“The downside of realignment is the counties are taking over a dismantled system,” said Catherine Camp, director of the California Mental Health Directors Assn. “It will take a long time to put it back together.”

There is also some question whether small, rural counties will be able or willing to handle the new responsibilities they have been given.

Others wonder if the new financing arrangements will withstand challenges based on Proposition 98 or on grounds that federal mandates have not been met.

But Sen. Dan McCorquodale (D-San Jose) said that, without realignment, mental health spending probably would have been slashed by another 40% next year.

And Mayer, the new state mental health director, believes the new approach will enable the state and counties to prove that “every patient can be treated. Not all will get better but most can live better lives in the community if they are properly managed.”