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California Mental Health Services Act
In November 2004, California voters passed Proposition 63, the Mental Health Services Act (MHSA), which expands California’s county mental health service systems with revenues raised through an additional one percent state income tax on individuals with taxable income in excess of one million dollars. The tax increase does not apply to corporations.
The MHSA initiative provides for developing a comprehensive approach to providing community based mental health services and supports for California residents. Approximately 25,000 to 30,000 taxpayers are directly affected by the new tax funding the initiative. The tax increase on these individuals was expected to generate $750 million in revenue during fiscal year 2005-06.
The MHSA addresses six components of building a better mental health system to guide policies and programs:
- Community program planning
- Services and supports
- Capital (buildings) and information technology (IT)
- Education and training (human resources)
- Prevention and early intervention
The MHSA stipulates that the California State Department of Mental Health (DMH) will contract with county mental health departments to develop and manage the implementation of its provisions. Oversight responsibility for MHSA implementation was handed over to the sixteen member Mental Health Services Oversight and Accountability Commission (MHSOAC) on July 7, 2005, when the commission first met.
The MHSA specifies requirements for service delivery and supports for children, youths, adults and older adults with serious emotional disturbances and/or severe mental illnesses. MHSA funding will be made annually to counties to:
- Define serious mental illness among children, adults and seniors as a condition deserving priority attention, including prevention and early intervention services and medical and supportive care
- Reduce the long-term adverse impact on individuals, families and State and local budgets resulting from untreated serious mental illness
- Expand the kinds of successful, innovative service programs for children, adults and seniors already established in California, including culturally and linguistically competent approaches for underserved population
- Provide State and local funds to adequately meet the needs of all children and adults who can be identified and enrolled in programs under this measure
- Ensure all funds are expended in the most cost-effective manner and services are provided in accordance with recommended best practices, subject to local and State oversight to ensure accountability to taxpayers and to the public.
Proposition 63 mandate
The requirements of the MHSA, mandated by approval of California Proposition 63 in 2004 with 53.4% of the vote, are intended to initiate significant changes, including:
- Increases in the level of participation and involvement of clients and families in all aspects of the public mental health system
- Increases in client and family operated services
- Outreach to and expansion of services to client populations in order to eliminate ethnic disparities in accessibility, availability and appropriateness of mental health services and to more adequately reflect mental health needs
- Increases in the array of services choices for individuals diagnosed with serious mental illness and children/youth diagnosed with serious emotional disorders, and their families.
Counties are required to develop their own three-year plan, consistent with the requirements outlined in the act, in order to receive funding under the MHSA. Counties are obliged to collaborate with citizens and stakeholders to develop plans that will accomplish desired results through the meaningful use of time and capabilities, including things such as employment, vocational training, education, and social and community activities. Also required will be annual updates by the counties, along with a public review process. County proposals will be evaluated for their contribution to achieving the following goals:
- Safe and adequate housing, including safe living environments, with family for children and youths
- Reduction in homelessness
- A network of supportive relationships
- Timely access to needed help, including times of crisis
- Reduction in incarceration in jails and juvenile halls
- Reduction in involuntary services, including reduction in institutionalization and out-of-home placements
MHSA specifies three stages of local funding, to fulfill initial plans, three year plans, and long term strategies. No services will be funded in the first year of implementation; it is anticipated county plans, and subsequent funding of new services, will be approved by DMH perhaps as early as January, 2006. Allocations for each category of funding will be granted annually, based upon detailed plans with prior approval. For the first year of implementation, the initiative allocates:
- 45% of available funds for local capital facilities and technology needs, including much of our existing planning for a new management and clinical information system
- 45% for education and training, including a State mandated local needs assessment identifying county staff shortages in each professional (and other) occupational category, in order to increase the supply of necessary staff counties anticipate will be required to provide for the service enhancements affoded by proposition 63, in accord with its intent
- 5% for county planning in developing both first stage plans and subsequent three year plans
- 5% of total available funds are to be reserved for:
- The California Department of Mental Health, for carrying out its collaborative role in implementing proposition 63
- The California Mental Health Planning Council, for its role in overseeing education and training initiatives
- The Mental Health Services Oversight and Accountability Commission
Department of Mental Health collaboration
In the first few months immediately following its passage, the DMH will:
- Obtain federal approvals and Medi-Cal waivers, State authority, additional resources and technical assistance in areas related to implementation
- Establish detailed requirements for the content of local three year expenditure plans
- Develop criteria and procedures for reporting of county and state performance outcomes
- Define requirements for the maintenance of current State and local efforts to protect against supplanting existing programs and their funding streams
- Develop formulas for how funding will be divided or distributed among counties
- Determine how funding will flow to counties and set up the mechanics of distribution
- Establish a 16 member Mental Health Services Oversight and Accountability Commission (MHSAOC), comprised of elected State officials and Governor appointees, along with procedures for MHSOAC review of county planning efforts and oversight of DMH implementation
- Develop and publish regulations and provide preliminary training to all counties on plan development and implementation requirements
The DMH has directed all counties to develop plans incorporating five essential concepts:
- Community collaboration
- Cultural competence
- Client/family-driven mental health system for older adults, adults and transition age youth and family-driven system of care for children and youth
- Wellness focus, which includes the concepts of recovery and resilience
- Integrated service experiences for clients and their families throughout their interactions with the mental health system
The DMH, in assuming and asserting its primacy over MHSA implementation, has dictated requirements for service delivery and supports as follows:
- Full Service Partnership Funds - funds to provide necessary services and supports for initial populations
- General System Development Funds - funds to improve services and infrastructure
- Outreach and Engagement Funding - funds for those populations that are currently receiving little or no service
Pharmaceutical industry influence
Few, if any, representatives of the pharmaceutical industry have openly participated in the town hall and stakeholder meetings during 2005. Many mental health clients and family members have requested easier access to less expensive medications during the initial stakeholder outreach process, while a similar number have expressed interest in alternative medicine options.
MHSA Oversight and Accountability Commission
Sixteen members have been appointed to the Mental Health Services Oversight and Accountability Commission (MHSOAC), whose role is to develop strategies to help mental health service clients overcome the social stigma of being labeled 'mentally ill', and to accomplish the objectives of the MHSA. Twelve members have been appointed by Governor Arnold Schwarzenegger, joining four State government appointed officials.
The Commission advises the governor and legislature regarding actions the State may take to improve care and services for people with mental illness, and is required to annually review and approve each county mental health program for expenditures. Whenever the commission identifies a critical issue related to the performance of a county mental health program, it may refer the issue to the DMH.
The first meeting of the MHSOAC was held July 7, 2005, at which time Proposition 63 author Darrel Steinberg was selected unanimously by fellow commissioners as chairman, without comment or discussion. After accepting the gavel, Steinberg was roundly praised for devising Proposition 63's 'creative financing' scheme. Steinberg then said, "We must focus on the big picture," and stated his priorities with regard to the implementation of the MHSA:
- Prioritize prevention and early intervention, without falling into the trap of fail first service provision,
- Address "the plight of those at risk of falling off the edge," and to
- Advocate for mental health services from his "bully pulpit."
In accordance with MHSA requirements, the Commission shall consist of 16 voting members as follows:
- The Attorney General or his or her designee
- The Superintendent of Public Instruction or his or her designee
- The Chairperson of the Senate Health and Human Services Committee or another member of the Senate selected by the President pro Tempore of the Senate
- The Chairperson of the Assembly Health Committee or another member of the Assembly selected by the Speaker of the Assembly
- Twelve appointees of the Governor, who shall seek individuals who have had personal or family experience with mental illness, to include:
- two persons with a severe mental illness
- a family member of an adult or senior with a severe mental illness
- a family member of a child who has or has had a severe mental illness
- a physician specializing in alcohol and drug treatment
- a mental health professional
- a county Sheriff,
- a Superintendent of a school district
- a representative of a labor organization
- a representative of an employer with less than 500 employees
- a representative of an employer with more than 500 employees
- a representative of a health care services plan or insurer
- CAIChildLaw.org - 'Sacramento County Funding Request for Mental Health Services Act Community Planning Program'
- CDCan.us - 'California Disability Community Action Network: Linking People to Disability Rights and Issues'
- DMH.cahwnet.gov - 'Mental Health Services Act (MHSA): Home Page', California Department of Mental Health
- DMH.cahwnet.gov - 'Mental Health Services Act (MHSA): MHSOAC (Mental Health Oversight and Accountability Commission) Home Page', California Department of Mental Health
- Governor.ca.gov - 'Governor Schwarzenegger Appoints Twelve to the Mental Health Services Oversight and Accountability Commission', Office of the Governor Press Room (June 21, 2005)