Listen to this note:
By Jocelyn Wiener. CalMatters
The consequences of our state's long history of failing to keep promises to people with serious mental illness are everywhere.
It can be found under our overpasses and in our tent encampments, but also inside our jails and prisons, our emergency rooms, schools and homes.
It shows up in our public opinion polls, which repeatedly list mental health as a top concern.
Increasingly, it is making its way into our political discourse. Referring to “our broken system,” Governor Gavin Newsom has in recent years implemented mental health policies at breakneck speed.
Now he’s pushing Proposition 1, a two-pronged measure on the March ballot that would fund a $6.4 billion bond for treatment beds and permanent supportive housing while also requiring counties to spend more of their existing mental health funds on chronically homeless people.
The measure also makes promises.
“These reforms and this new investment in behavioral health housing will help California deliver on promises made decades ago,” Newsom said.
What promises has California made to people with mental illness over the years? And why are so many still suffering?
Here's a brief timeline of mental health policies in our state (of promises made and promises broken) over the past 75 years.
1950s and 1960s: An era of institutionalization
In the 1950s, it was relatively easy to force people into state mental hospitals, many of which had horrific conditions. Patient numbers peaked in the late 1950s at approximately 37,000. During that time, the state began to shift control of mental health services to the counties, embarking on the process of deinstitutionalization. This process accelerated in the late 1960s with the passage of the landmark Lanterman-Petris-Short Act, a law designed to protect the civil rights of people with mental illness.
1954: The Food and Drug Administration approves chlorpromazine (Thorazine), the first antipsychotic drug, to treat people with serious mental illness.
1957: The California Legislature increases funding for community mental health under the Short-Doyle Act, with the goal of treating more people in their communities rather than in state hospitals.
1963: President John Fitzgerald Kennedy signs the Community Mental Health Act, pledging federal leadership to build and staff a network of community mental health centers. Less than a month later, he is assassinated. Many of the clinics are never built.
1965: Congress creates Medicare and Medicaid, allowing people with mental illness to receive treatment in their communities.
1967: Then-Gov. Ronald Reagan signs the Lanterman-Petris-Short Act, limiting involuntary detention for all but the most severely disabled mentally ill and providing them with legal protections.
1970s and 1980s: California tax revolt leads to austerity
As state psychiatric hospitals closed in the 1970s, many people with serious mental illness were moved into for-profit nursing homes and retirement homes. Their numbers on the streets and inside jails and prisons began to rise. The 1980s saw major funding cuts to mental health services at both the state and federal levels.
1978: The Community Residential Treatment Systems Act seeks to create unlocked, non-institutional alternatives for people with mental illness throughout California.
The same year, voters approve Proposition 13, which caps property taxes and reduces the amount of money available to counties for a variety of services, including mental health.
1980: President Jimmy Carter, who a few years earlier created a Presidential Commission on Mental Health at the urging of his wife Rosalynn, signs the Mental Health Systems Act to fund the community mental health centers envisioned by President Kennedy.
1981: President Ronald Reagan signs the Omnibus Budget Reconciliation Act, which repeals most of Carter's Mental Health Systems Act and returns responsibility for people with serious mental illness to the states.
1990s: Local control of mental health services
In the decade, funding and responsibility for mental health services shift from the state to counties. California passes a law to hold health plans accountable for providing adequate mental health treatment.
1991: The state Legislature approves a “realignment”: moving funding and responsibility for many mental health services from the state to the counties.
1995: The state implements Medi-Cal Mental Health Managed Care, making counties responsible for providing many Medicaid mental health services.
1999: California passes a state parity law requiring private health plans to provide equal coverage for serious mental illness and physical health.
The same year, the Homeless Mental Illness Act, a pilot program to assist homeless people with serious mental illness and an important precursor to the Mental Health Services Act, is implemented in three counties.
2000s: New resources for mental health care
Optimism about the state's ability to finally address the needs of people with mental illness is growing with the passage of the landmark Mental Health Services Act. But the Great Recession of the latter part of the decade threatens some of that progress.
2002: The Legislature passes Laura's Law. Named after a young woman killed by a man who refused psychiatric care, the law allows, but does not require, counties to create court-ordered treatment programs.
2004: California voters approve the Mental Health Services Act. The $11.3T tax on individuals with incomes over $1.3T provides a new source of revenue to bolster county mental health systems.
2008: A federal parity law, the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act, requires health plans that offer coverage for mental health and substance use disorders to provide benefits comparable to those offered for medical and surgical treatments.
2010s: Homelessness takes center stage
The number of people with serious mental illness who are experiencing homelessness continues to rise. Jails and prisons are now the largest mental health providers in the country, and a backlog of incarcerated people deemed incompetent to stand trial is drawing increasing scrutiny. The number of children and adolescents entering hospitals in mental health crises is beginning to rise.
2010: The Affordable Care Act (Obamacare) requires insurers to provide mental health as an essential benefit.
2011: The Great Recession causes major budget cuts, pushing some people out of the public mental health system. A second movement or “realignment” of mental health and substance use disorder services shifts even more funding and responsibility from the state to counties.
2012: California eliminates its Department of Mental Health and distributes its responsibilities among other state departments.
2013: The Mental Health Wellness Law injects about $143 million to increase the capacity of the state mental health crisis response system.
2018: California voters approve a ballot measure called No Place Like Home to build and rehabilitate supportive housing for people with mental illness. The measure authorizes the use of Mental Health Services Act funds to pay $2 billion in bonds.
That same year, Newsom is elected governor and promises to make mental health a major focus of his administration.
2020s: Newsom's mental health agenda
In the wake of the COVID-19 pandemic, the large number of people with mental illness on the streets, coupled with the fentanyl epidemic and a growing mental health crisis among children and adolescents, is driving heightened public interest in mental health. The Newsom administration is making unprecedented investments and implementing a steady stream of major policy changes. Critics charge that some of these changes move the state toward more involuntary treatment.
2020: California passes a “groundbreaking” new state parity law, greatly expanding its previous law and making it a national leader in requiring commercial health plans to provide mental health services.
2021: Newsom Administration Allocates $1.6 Billion in One-Time Funding for a Child and Youth Behavioral Health Initiative.
2022: The administration creates Community Assistance, Recovery, and Empowerment (CARE) Courts, new court systems to address the needs of people with serious mental illness that have some echoes of Laura’s Law. This time, county involvement is not optional.
That same year, a massive statewide effort called California Advancing and Innovating Medi-Cal (CalAIM) begins to roll out, promising to expand and streamline access to mental health care for people insured by Medi-Cal, the public insurance program for low-income Californians.
2023: Newsom signs legislation amending the definition of “severe disability” originally set in the landmark 1967 law limiting involuntary confinement in the state. The amendment makes it easier to confine people with severe mental illness by stripping them of their rights and entrusting their care to public guardians.
2024: Proposition 1 goes before voters. If approved, it will provide billions in new funding for permanent supportive housing and treatment beds, and set new parameters for how Mental Health Services Act funds are used.
This timeline was reported with the help of dozens of news articles and government and academic reports, as well as interviews and historical information provided by a variety of people, including Steve Fields, Adrienne Shilton, Michelle Cabrera, Corey Hashida, Stacie Hiramoto, Randall Hagar, Diane Van Maren, Chad Costello, and Alex Barnard’s 2023 book “Guardianship: Inside California’s Mental Illness Coercion and Care System.”
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