End-of-Session Update from CEO Jessica Cruz
A Marquee Year for Mental Health Reforms Thanks to Our Collective Voice
First and foremost, I want to thank our advocates who continue to serve as a powerful voice for those experiencing severe mental illness, their caretakers and loved ones. The California Legislature concluded its 2023 session last week and mental health was at center stage. NAMI California fought tirelessly to advance critically necessary policy to ensure the inclusion of services for individuals living with serious mental illness and their families.
Earlier this year, we outlined our legislative priorities, including:
Modernizing the meaning of gravely disabled
NAMI California co-sponsored SB 43 (Eggman), legislation that modernizes the meaning of gravely disabled within the Lanterman-Petris-Short (LPS) Act to better meet the needs of individuals experiencing severe mental illness, providing families with the ability to secure needed treatment for their loved ones experiencing severe mental illness. We are thrilled to share the bill is now headed to the Governor’s desk.
Shaping the future of the MHSA
With next year marking the 20th Anniversary of the enactment of the Mental Health Services Act (MHSA), this legislative session was the ideal time to reflect on the current model and identify opportunities.
NAMI California’s voice was instrumental in getting the MHSA passed in 2004. There is a reason that MHSA’s heart is “client AND FAMILY driven.”
It’s thanks to our collective voice. We were pleased to have a seat at the table then, and in subsequent years as it’s been implemented. While the MHSA has positively transformed the public mental health system, addressing the critical needs of those living with serious mental illness has gradually diminished along the way.
This Legislative session, we were presented with a package of reforms intended to modernize the MHSA and overhaul our state’s behavioral health landscape through SB 326 (Eggman – D) and AB 531 (Irwin – D).These bills provide an extension of services to individuals struggling with substance use disorders (SUD) along with continued support for those with severe mental illnesses. The proposal also includes additional resources for housing, including involuntary and voluntary care, particularly for those facing persistent homelessness, with a special emphasis on veterans contending with behavioral health challenges.
NAMI California remained dedicated to ensuring that the MHSA’s original intent was upheld in these modernization efforts. We fought for necessary amendments to this proposed package including oversight to ensure counties are accountable for investments and that those investments are aligned with the original intent of the MHSA, which is client and family driven.
We advocated for amendments to ensure the MHSA’s original intent remained intact, including:
- Outreach and Engagement
- Enhanced State Oversight
- Stigma Reduction and Prevention
As a result of NAMI’s advocacy efforts, the proposal now reinstates required voter approval of amendments to the MHSA, ensures a 5% increase in the Behavioral Health Supports and Services funding bucket and includes supportive services like Family Engagement and Psychoeducation. NAMI California also advocated to ensure AB 531 included the use for acute and subacute beds to ensure full spectrum care is available.
We must do all we can, in any piece of legislation, to ensure our limited resources are used efficiently and effectively. In the MHSA, this means utilizing the funding for the families and individuals who are dealing with the most serious and complex mental illnesses who need intensive supports and services, as the MHSA originally intended. These brave individuals deserve to live happy and productive lives.
Through collaboration, dedication to ensuring amendments were included and support of our fierce advocates, NAMI California is proud to support this package and we are pleased to share that both bills are now heading to the Governor’s desk for signature.
Thank you to our advocates
Our role is to ensure a strong behavioral healthcare system in California that provides support for individuals and families, and we’ve never been more successful. As a family-driven advocacy organization, NAMI California is dedicated to ensuring that the needs of those experiencing serious mental illness and their families are met and that critical resources are available. Today we are celebrating a historic time where the needs of the behavioral health community are at the forefront of our state’s legislative priorities. We could not be more proud, and thank you for your support.
Priorities and Policy Positions
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An Update on the Proposed Modernization of the MHSA
- Allowing Outreach and Engagement: These activities are now a category within the Behavioral Health Services and Supports bucket. Advocacy is needed to ensure family programs are included in this definition, which we will continue to advocate for.
- Enhanced State Oversight: The amendments clarify and strengthen the state’s role in overseeing the MHSA.
- Focus on Reducing Stigma and Prevention: Reducing stigma and prevention is now specifically stated as a condition for receiving population-based prevention funding and will be administered by the California Department of Public Health for both statewide and local programs.
- Voter Approval Requirement: As a result of NAMI’s advocacy efforts, the proposal now reinstates required voter approval of amendments to the MHSA.
- Housing Interventions: These are not restricted to only Medi-Cal enrollees.
- Optional SUD Services: Counties now have the option to provide substance use disorder (SUD) services, based on a stakeholder process and three-year plan data.
- Increase in Behavioral Health Support: As a result of NAMI’s advocacy efforts, there is now a 5% increase in the Behavioral Health Supports and Services Bucket, with a new breakdown:
- 35% for Behavioral Health Services & Supports
- 35% for Full-Service Partnerships
- 30% for Housing Interventions
- Inclusion of Supportive Services: As a result of NAMI’s advocacy efforts, amendments include supportive services like Family Engagement and Psychoeducation.
Preliminary May Revise of the State Budget for 2022-23 – Behavioral Health Issues
Governor Gavin Newsom presented the May Revision of his January budget proposal on May 13, and for the first time, the governor’s budget has surpassed $300 billion. The purpose of the Revision is to update revenues based on tax receipts and present any new administrative proposals or changes to the governor’s January proposal. The summaries below primarily reflect changes or additions to the governor’s proposed budget. Unless withdrawn, all of the governor’s proposals from January remain on the table.
A top priority for NAMI-CA, CARE Court is the governor’s proposal which aims to deliver services to Californians with a serious mental illness or substance use disorder who too often languish – suffering in homelessness or incarceration – without the treatment they desperately need. CARE Court would authorize specified persons – including family members, behavioral health providers, first responders, or other approved parties – to petition a civil court to create a CARE plan and implement services for individuals suffering from specified mental health disorders. If the court determines the individual is eligible for the CARE Court Program, the court would order the implementation of a CARE plan, as devised by the relevant county behavioral services agency, and would oversee the individual’s participation in the plan.
There are still many unanswered questions surrounding process and the funding mechanisms, but the May Revise responds to the funding with a $65 million investment:
The May Revision proposes the following resources for CARE Court:
- $10 million General Fund ongoing to the Department of Aging for the CARE Court Supporter Program.
- $15.2 million General Fund in 2022-23, $1.1 million General Fund annually between 2023-24 and 2026-27, and $1.3 million General Fund annually to the Department of Health Care Services for training and technical assistance to counties, data collection, and evaluation.
- $39.5 million General Fund in 2022-23 and $37.7 million ongoing for the Judicial Branch to conduct CARE Court hearings and provide self-help centers.
- The Department of Finance has additionally stated their commitment to fund new county costs.
Housing & Homelessness
Housing Production and Climate Resiliency: The May revise invests $500 million over two years to assist in building more downtown-oriented and affordable housing by converting existing infrastructure, underutilized retail space, and commercial buildings into residential buildings. This brings the total adaptive reuse proposals from the governor to $600 million over three years.
Homekey: $150 million in additional resources is proposed by the administration to total $2.9 billion in Homekey funding over two years.
Local Government Grants: As part of the May Revise, the governor is proposing $500 million over two years to house homeless individuals on state-owned land through grants to local governments for interim housing and site preparation.
Health & Human Services
Felony Incompetent to Stand Trial (IST): $535.5 million General Fund in 2022-23, increasing to $638 million General Fund in 2025-26 and ongoing is included in the May Revise to provide:
- Funding for county sheriffs for custody supports and increased access to ISTs for stabilization teams.
- County overhead support for administration of community-based restoration, diversion, and community housing.
- Improvements in discharge planning for continuity of treatment.
- Improvements in the determinations and decisions about the need for medications.
Opioid Response: $41.8 million Opioid Settlements Fund from additional projected proceeds is proposed in the May Revision.
- $29.1 million for substance use disorder workforce training to total $51.1 million.
- $10 million for the naloxone distribution project targeting the homeless to total $15 million.
- $2.7 million for a public awareness campaign targeting youth opioid and fentanyl risk education to total $40.8 million.
California Advancing and Innovating Medi-Cal (CalAIM): The May Revision includes $1.1 billion ($459 million General Fund) in 2021-22 and $3.1 billion ($1.2 billion General Fund) in 2022-23, and includes updates to:
- Delay the transition of Intermediate Care Facilities for the Developmentally Disabled (ICF-DDs) and Subacute Care Facilities into managed care from January 1, 2023 to July 1, 2023.
- Population Health Management (PHM) Service is now anticipated to go live statewide in July 2023, with additional PHM Service capabilities incrementally phased in thereafter.
- Additional transitions to managed care – DHCS is working to identify which additional individuals will need to transition.
- The estimated cost of inmate pre-release has been updated to reflect the inclusion of expanded pharmacy services. DHCS is proposing to cover medications consistent with the full scope of covered outpatient drugs under Medi-Cal State Plan as part of the 90-day pre-release services.
- The federal Centers for Medicare and Medicaid Services has not yet approved the Department’s request to reinstate federal reimbursement for certain Designated State Health Programs (DSHP). While negotiations continue, the Department has replaced CalAIM DSHP funding with General Fund support in order to ensure sufficient funding authority.
- Trailer bill language is proposed to align the federal approvals received for CalAIM; authorize DHCS to seek federal approval for an 1115 Serious Mental Illness/Serious Emotional Disturbance Waiver; and delay the transition of ICF-DDs and Subacute Care Facilities into Medi-Cal managed care from January 1, 2023 to July 1, 2023.
Children’s Behavioral Health: The governor provides $290 million General Fund in the May Revision for the youth mental health crisis.
- $40 million General Fund for community-based youth suicide prevention for youth at increased risk of suicide such as Black, Native American, Hispanic, and foster youth.
- $50 million for grants to pilot school and community-based crisis response and supports following a youth suicide or suicide attempt and pilot the designation of youth suicide or suicide attempts as a reportable public health event.
- $85 million over two years for grants for wellness and mindfulness programs and an expansion of parent support and training programs.
- $15 million to develop and distribute a video series for parents on children’s behavioral health.
- $25 million for the career development of 2,500 culturally diverse high schoolers interested in mental health careers.
- $75 million for digital supports for remote and metaverse based mental health assessment and intervention.
CalHOPE Extension: $10.9 million General Fund in 2021-22, $80 million General Fund in 2022-23, and $40 million General Fund in 2023-24 is proposed to continue providing crisis counseling after Federal Management Agency grant funding ends.
Los Angeles County Misdemeanor Incompetent to Stand Trial Services and Supports: The administration is proposing $100 million General Fund for L.A. County to support access to community-based treatment and housing. This proposal replaces lease revenue bond authority competitively awarded to L.A. County through the Board of State and Community Corrections.
LGBTQ+ Youth: The administration provides $5 million for grants to counties and community-based organizations to improve capacity, training, and culturally responsive care.
Administration of Justice
Officer Wellness Grants: $50 million General Fund is proposed to fund grants to improve officer health and improve community trust and relations.
Mobile Probation Centers: The May Revise includes $20 million General Fund to establish a competitive grant program for counties to create mobile probation centers.
Post Release Community Supervision: The May Revision provides $20.9 million General Fund, a reduction of $2.3 million from January’s estimate due to lower prison release projections.
Drug Interdiction Efforts: The governor is proposing a $10 million augmentation to the $20 million he proposed to expand the California Military Departments drug interdiction efforts in four High Intensity Drug Trafficking Areas ($15 million in 2022-23 and $15 million in 2023-24).
Prison Capacity and Closures: Deuel Vocational Institution in Tracy was closed in September 2021, providing state savings of $150.3 million annually beginning in 2022-23. The State intends to close the California Correctional Center in Susanville saving $122 million annually, however, the City is currently litigating the closure. The administration estimates that based on prison population projections, three additional state prisons may be closed by 2024-25.
NAMI CA Official Position on the CARE Court — Support
Dear Governor Newsom:
NAMI-CA is in support of the Administration’s CARE Court framework, which intends to deliver services to Californians with a serious mental illness or substance use disorder who too often languish – suffering in homelessness or incarceration – without the treatment they desperately need.
NAMI-CA is the statewide affiliate of the country’s largest mental health advocacy organization, the National Alliance on Mental Illness. Our over 110,000 active advocates and 58 affiliates include many people living with serious mental illnesses, their families, and supporters. NAMI-CA advocates on their behalf, providing education and support to its members and the broader community.
NAMI-CA believes that all people should have the right to make their own decisions about medical treatment. However, we are aware that there are individuals with serious mental illnesses who have very high complex needs, at times, due to their illness, lack insight or good judgment about their need for medical treatment. In cases like this, a higher level of care may be necessary, but must be the last resort. Our members have been calling for reform for their loved ones for years.
NAMI-CA believes that the availability of effective, comprehensive, community- based systems of care for persons suffering from serious mental illnesses will diminish the need for assisted outpatient treatment. Before we reach the stage of last resort, we must fully fund, build and staff our community-based system, so all who need care can access it long before they reach a crisis level.
NAMI-CA urges the state to ensure that any services that are made available through the CARE Court model are also available as voluntary services in the community care continuum. There is currently no statewide standard that specifies that specific services be available to all people in all counties. We can no longer accept a fail-first system composed of partially realized solutions.
NAMI-CA deplores the higher rates of involuntary commitment and incarceration in penal facilities that occurs among communities of color with serious mental illnesses. We are thankful to have an Administration that understands that equity must be a top tenet of policymaking. Recognizing that communities of color and other underrepresented communities often suffer the unintended consequence of the court system serving as their behavioral health delivery system, the Administration must work closely with underrepresented communities to ensure that CARE Courts serve as an example of health equity in action.
NAMI-CA is heartened to see that accountability is one of the pillars of the CARE Court framework. We must hold the system accountable at all delivery points. We cannot take anything for granted in the implementation of a framework, as its effectiveness lies in the words that end up in statute, how it is implemented through the regulatory process, and to how each of our 58 counties will interpret the framework.
Additionally, more can be done to ensure the public (family members and consumers, in particular) and policymakers have the information they need to be assured that public programs treating people with serious mental illness are doing so effectively. In particular, little information is currently collected or shared about one of the most profound roles government plays in the mental health field – involuntary evaluation, treatment, and conservatorship under the LPS Act.
Many questions remain to be answered. What will the court process look like? What does success look like? If an individual has been diverted from legal proceedings, will their record be expunged upon completion of the CARE Court process? Who will qualify as a Supporter? What new resources will be directed to the proposal other than the preexisting federal, homelessness and county funds that were underscored in the framework? NAMI-CA looks forward to working closely with the Administration to implement the promise of the CARE Court framework.
I may be reached at firstname.lastname@example.org or (916) 567-0163. Sincerely,
Chief Executive Officer
Cc: Ana J. Matosantos, Cabinet Secretary, Office of Governor Gavin Newsom
Dr. Mark Ghaly, Secretary, California Health and Human Services Agency (CHHS) Stephanie Welch, Deputy Secretary, CHHS
Michelle Baass, Director, DHCS
Dr. Kelly Pfeifer, Deputy Director, Behavioral Health, DHCS
Stephanie Clendenin, Director, DSH
Mary Watanabe, Director, DMHC
Richard Figueroa, Office of the Governor
Tam Ma, Office of the Governor
Marjorie Swartz, Office of the Senate President Pro Tempore
Chris Woods, Office of the Senate President Pro Tempore
Agnes Lee, Office of the Speaker of the Assembly
Jason Sisney, Office of the Speaker of the Assembly
Joe Parra, Senate Republican Fiscal Office
Joe Shinstock, Assembly Republican Fiscal Office Corey Hashida, Legislative Analyst’s Office (LAO) Ben Johnson, LAO
2023 State Legislation
Summary: This bill would establish a real-time, internet-based dashboard to collect, aggregate, and display information about beds in inpatient psychiatric facilities, crisis stabilization units, residential community mental health facilities, and licensed residential alcoholism or drug abuse recovery or treatment facilities. Access to an up-to-date database of available beds helps providers quickly find and secure treatment for clients in appropriate settings, reducing delays or extended stays in emergency rooms.
8.9 Evaluation of Programs
NAMI CA believes that all programs in the public mental health system should be regularly and rigorously evaluated to ensure best outcomes for those they serve.
(8.9.1) Data collection practices, deliverables, and outcome measurements should be established at the outset of all new programs; consumers, families, and stakeholders must be meaningfully involved in this process.
Summary: This bill would also modernize the definition of “gravely disabled” within the Lanterman-Petris-Short (LPS) Act to better meet the needs of individuals experiencing severe mental illness. SB 43 would include under the definition of “gravely disabled” a condition in which, as a result of a mental health disorder or substance use disorder, there is a substantial risk of serious harm to a person’s mental or physical health.
This bill allows a court to consider relevant testimony during conservatorship proceedings by creating a hearsay exception for medical history that is contained in the medical record.
Access to Treatment
Summary: A recent state study showed that 24 California counties have no inpatient psychiatric beds today and at least 480 more beds are needed to meet statewide needs. It is not uncommon for our loved ones in mental health crisis to languish in hospital emergency departments for days or even weeks while waiting for an inpatient bed to become available.
In some communities, the county mental health department manages the transfer process for patients on a hold, and in other cases, the hospital manages it. Hospitals report that it can take disproportionately longer when waiting for the county to find an inpatient psychiatric bed than it does when the hospital is able to make transfer arrangements.
This bill clarifies that hospital emergency departments should transfer patients in crisis to accepting inpatient psychiatric hospitals, regardless of whether a person is on an involuntary hold.
The bill also makes it clear that Medi-Cal managed care plans bear full responsibility for emergency department services to a member experiencing a mental
(9.2.15) Private and public health insurance and managed care plans should cover the costs of involuntary inpatient and outpatient commitment and/or court-ordered treatment.
Summary: SB 282 addresses barriers that patients in California face when attempting to access comprehensive health services by allowing their local community health center to bill Medi-Cal for mental health services and other medical services in the same day.
In California, if a patient receives treatment through Medi-Cal at a community health center from both a medical provider and a mental health specialist on the same day, the State Department of Health Care Services will only reimburse the center for one “visit,” meaning it cannot be adequately reimbursed for its services. A patient must seek mental health treatment on a subsequent day for that treatment to be reimbursed as a second visit.
This creates an undue financial barrier for community centers, known as Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs), preventing them from treating their patients in a comprehensive manner in the same day.
Allowing health centers to access the same-day billing statute already in place in other public programs will ensure more early intervention in mental illness and guarantee that we are using the integrated health services available to our communities at their full potential.
Children & Youth
Summary: Surveys show that when accessing for mental health services, making parental opt-in mandatory reduces teens’ likelihood of seeking timely treatment, especially amongst LGBTQ+ and youth of color. California recognized this in 2010 and addressed it with SB 543, allowing youth 12 and up to consent to mental health care. However, the law explicitly excludes youth on Medi-Cal from utilizing their benefits when their parents have not granted consent to be billed for mental health care.
This bill merely aligns consent standards for all young people by not requiring youth on Medi-Cal to meet a higher standard of need than their peers on private insurance – i.e. eliminates the imminent danger of self-harm, or being the victim of child abuse, for the Medi-Cal plan to pay for services.
After consulting with the youth, this bill still allows providers to work with the youth’s parent(s) as a part of their treatment.
2.8.2 NAMI California believes that, at the earliest possible time in their lives, all children and adolescents with serious mental illnesses deserve to be diagnosed, appropriately treated, and offered the services necessary to achieve and maintain their recovery.
Summary: This bill requires the CA Department of Education to ensure that 75 percent of certificated and classified employees on school campuses complete an evidence-based behavioral health training program. This instruction would guide school staff on how to provide referrals to mental health services, substance use disorder services, and other support to individuals in the early stages of developing a mental illness or substance use disorder.
This bill would also build on the success of SB 224 (Chapter 675, Statutes of 2021), and will require all students between grades 1-12 to receive evidence-based, age-appropriate mental health education at least once in each of elementary, middle, and high school, respectively.
Summary: In Paid Family Leave (PFL) eligibility, updates the definition of “family member” so qualifying California workers will be able to access PFL wage replacement benefits to care for a member of their chosen or extended family.
Public Policy Survey 2022 – Priority #2 Family Involvement in Treatment
Summary: Prohibits discrimination against employees based on their status as a family caregiver (i.e. hiring).
More than 1 in 6 Americans working full-time or part-time report assisting with the care of an elderly or disabled family member, relative, or friend and over 1 in 12 employed adults are caring for both children and elderly or disabled adults. Most employees will have caregiving responsibilities at some point in their professional lives.
Family caregiver discrimination occurs when an employer takes a negative employment action against an employee based on their status as a caregiver. Employment actions—like termination, refusal to hire, or demotion—may be based on biases about how workers who are caregivers will or should act, without regard to the workers’ actual performances or preferences.
This bill would prohibit employers from discriminating against employees based on their status as a caregiver by adding “family caregiver status” to the list of protected characteristics (e.g., race, sexual orientation, marital status, religion, etc.) that are already prohibited bases of discrimination under the employment provisions of the Fair Employment and Housing Act.
Public Policy Survey 2022 – Priority #2 Family Involvement in Treatment
Summary: This bill amends the current form for Advance Health Care Directives to allow an individual to appoint a separate agent for mental health decision making. This bill also creates a new section within the Advance Health Care Directives form specifically for mental health care planning.
A Psychiatric Advance Directive (PAD) is a legal document created by an individual to record their preferences for mental health treatment in the event of a future crisis. PADs are demonstrated to reduce the need for coercive interventions during mental health crises and increase participants’ feelings of autonomy, self-determination and empowerment. PADs can also improve mental health outcomes by facilitating conversations between mental health providers and an individual in mental health crisis.
California currently permits adults, in a very limited way, to document advance planning for mental health care decision making through an Advance Health Care Directive (AHCD).
While California’s statutory template for an Advance Health Care Directive form includes health-related information such as end-of-life decisions and relief from pain, it does not include questions related specifically to mental health care. Thus, when mental health care decisions are created within Advance Health Care Directives, the result is incomplete and fails to address issues critical to mental health care such as facility choice, provider choice, medication preferences, and emergency interventions.
9.3 Advance Directives and Healthcare Proxies
NAMI California supports efforts of persons with serious mental illnesses, family members, caregivers and service providers to work collaboratively to develop plans for treatment, services, and supports that are followed, when, and if, needed in the future.
Summary: This bill would create a state-run housing subsidy program for elderly people and those with disabilities at highest risk of becoming homeless.
The state would administer and offer competitive grants to nonprofit organizations, continuums of care, and other organizations. HCD will select grantees with the resources, expertise, and cultural specificity to provide assistance to households experiencing or at risk of homelessness. Grants will prioritize communities in which a high proportion of the renters face cost burdens.
Grantees will provide subsidies to help older adults and adults with disabilities remain housed, with subsidies covering the difference between 30% of a person’s household income and the unit’s reasonable rent. Such subsidies will likely prevent and end homelessness for thousands of older and disabled adults. Studies show low-income renters accessing housing subsidies are able to remain housed or exit homelessness for good.
(5.3.3) Housing options should offer appropriate supportive services, including but not limited to: case management; tenancy support; clinical services; employment training and education; transportation; and crisis intervention. Housing should also be monitored by the appropriate licensing and enforcement agencies for quality, including cleanliness and safety.
2022 Survey Priority 4 – Housing
Summary: This bill ends the use of solitary confinement for designated populations, including:
– People with a mental illness
– Those with disabilities
– Pregnant women
– Other vulnerable populations
10.11 NAMI California opposes the use of solitary confinement in Secure Housing Units (SHU) for individuals living with mental illness that are incarcerated with the California Department of Corrections and Rehabilitation (CDCR).
Due to a lack of mental stimulation, psychological research has found that inmates subjected to solitary confinement suffer from a variety of psychological and psychiatric illnesses. For inmates who are already diagnosed with serious mental illness, such confinement severely exacerbates their conditions. We believe that, even when incarcerated, individuals living with mental illness have a right to humane, effective treatment in the least restrictive but secure setting.
Summary: This bill will allow defendants diagnosed with Borderline Personality Disorder (BPD) to be eligible for pretrial diversion on an accusatory pleading of a misdemeanor or felony. The defendant will not be allowed to undergo pretrial diversion for murder, manslaughter, rape, and sexual abuse charges.
BPD is one of the most prevalent mental disorders as it accounts for approximately 1.6 – 5.9% of the world’s general population, with slightly higher rates among women and younger individuals.
Because BPD is among the most misunderstood disorders, it is often stigmatized. There is limited data in this area because BPD is almost always co-occurring with other mental disorders including: depression, generalized anxiety and bipolar disorder. The exclusion of BPD from diversion eligibility is not data driven and perpetuates harmful stigma about the disorder and limits access to care for people at high risk of suicide.
AB 1412 will amend California Penal Code 1001.36 by striking borderline personality from the exclusionary list of mental disorders. AB 1412 will ensure that Californians living with borderline personality disorder have equitable access to pretrial diversion and strive to reduce recidivism within an often-misunderstood population.
(10.7.1) NAMI California believes that persons who have committed offenses due to states of mind or behavior caused by a serious mental illness do not belong in penal or correctional institutions. Such persons require treatment, not punishment. A prison or jail is never an optimal therapeutic setting.
Summary: This bill would ensure that mental health therapy is accessible to incarcerated Californians, regardless of security level, sentence length, or mental health classification.
There are approximately 97,000 people incarcerated in California’s prisons. The California Department of Corrections and Rehabilitation (CDCR) currently only provides therapy to the most severe cases of mental illness – those assigned to one of four classifications:
- Core Clinical Case Management System (Triple-CMS): the lowest classification level, with therapy at least once every 90 days
- Enhanced Outpatient Program (EOP): the highest level of outpatient mental care, patients whose symptoms impact their ability to function, and who live in separate housing
- Mental Health Crisis Bed (MHCB) – typically less than 10 days for patients who are deemed a danger to themselves or others, and are in acute psychiatric distress
- Psychiatric Inpatient Programs (PIP) – acute and immediate care, often suicidal patients
Currently, around 30,000 incarcerated people fall into one of these classifications. These individuals who may access therapy in prisons have sessions as short as 15 minutes, and often cycle through different therapists sporadically. Thus, building a rapport with their therapist and establishing consistency is impossible.
Approximately 67,000 incarcerated Californians who are not classified are left without access to any mental health care at all, given people with mental health issues are far over-represented in California’s prisons. Many people find themselves in criminogenic settings as a result of trauma, post-traumatic stress disorder (PTSD), addiction, and depression that has not been addressed and is exacerbated by their time in prison. The Prison Police Initiative found that people’s experiences in jails and prisons within correlate to the development of adverse mental health effects.
SB 513 allows CDCR to increase virtual or in-person therapy opportunities to all incarcerated people, to the greatest extent possible. The bill redefines “mental health therapy” as 50-minute sessions offered up to two times per month by a psychiatrist, psychologist, licensed social worker, or licensed therapist. The bill will also require CDCR to provide incarcerated people with a mental health appointment within two weeks of the patient requesting care and will ensure patients are seen on schedule, on time, and confidentially.
(10.6.1) Humane and effective treatment for serious mental illnesses while in correctional settings is the constitutional right of inmates with severe mental illnesses. NAMI California strongly urges the enactment of state statutes expanding treatment programs within prison and jail settings, including first-line access to new generation medications whenever clinically indicated.
(10.6.2) NAMI California endorses state laws and policies establishing systems of community treatment for offenders with serious mental illnesses who are released on parole and/or are in the community on probation or parole status.
Support NAMI CA This Tax Season
Take Action: Support the NAMI California Sponsored Mental Health Crisis Prevention Tax Contribution Fund – Line 445 on California Form 540.
Support Mental Health & Public Safety
This tax season, help NAMI California strengthen mental health and public safety by contributing to the Mental Health Crisis Prevention Tax Contribution Fund – Line 445 on California Income Tax Form 540. The fund supports an innovative program that provides training, tools, and resources to law enforcement agencies to safely interact with and support individuals experiencing a mental health crisis. According to the U.S. Department of Justice (DOJ), 25% of fatalities and 40% of injuries in officer involved shootings involve a person with a mental illness. NAMI California experts and public safety leaders agree that increased support and education for law enforcement officials is critical to safely engage people living with a mental illness. With these skills, officers can connect people experiencing a mental health crisis to treatment, counseling and other supports aiding in recovery.
Mental health is more important now than ever before. Learn how you can support the NAMI California Sponsored Mental Health Crisis Prevention Tax Contribution Fund >>
People who have committed offenses due to states of mind or behavior caused by a serious mental illness do not belong in penal or correctional institutions. Such persons require treatment, not punishment.
More than 115 respondents from across California participated in our recent survey to provide their experience with the IST process and try to improve the system for families in the future.
Take Action: National Policies
Urge Congress to Fund Crisis Services
Next year, 988, a 3-digit number for mental health crises, will be available nationwide. But what crisis services will be available in your community if you or someone you know needs this life-saving line? NAMI is urging Congress to fund mental health crisis services. We need you to email your member of Congress to help ensure that there is more federal funding for crisis services in your community. Find out more and sign NAMI’s petition.
Urge Congress to Support Mental Health Research
Imagine if cancer, heart disease or diabetes was diagnosed just by using a short list of questions to assess symptoms. Sadly, due to the complexity of the brain and lack of strong research, this is how people are currently diagnosed with mental health conditions. This results in many mistakes in diagnosis and ineffective treatment. We need Congress to invest in research for mental health conditions. Find out more and sign NAMI’s petition
Support NAMI National’s Advocacy Actions
Be a Local Advocate
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Preliminary State Budget Update for 2022-23 – Behavioral Health Issues
The COVID-19 pandemic has exacerbated behavioral health needs and placed significant demands on the existing system of care. Workforce shortages have widened the inequities across the system, worsened by the COVID-19 Pandemic. Californians across all demographics, but especially youth, communities of color, and LGBTQ individuals, and other disadvantaged Californians are experiencing increased levels of stress, anxiety, depression and isolation. In California, consistent with national trends, overdose deaths have risen as well as suicidal ideation and hospitalization for self-harming behavior.
Thanks in part to a budget surplus in the tens of billions of dollars (projected between $32 and $46 billion), the Governor’s $286.4 billion Budget has made substantial new investments in behavioral health programs to meet the behavioral health needs of all Californians, and particularly those most vulnerable such as individuals experiencing homelessness and those who are justice-involved,
Below, you will find the behavioral health items included in the Governor’s proposed State Budget for Fiscal Year (FY) 2022-23, which was released on January 10. The Legislature now begins its work of vetting and approving, rejecting or modifying the various proposals in the governor’s budget through the budget subcommittee process, which will go into the month of March. Please note that updated information will be provided as additional and final actions are taken by the Legislature. The Legislature must pass the budget by June 15 in order to begin the fiscal year on July 1.
GOVERNOR HINTS AT MAJOR CHANGES TO COME
In addition to all of the funding proposals announced yesterday, the Governor also hinted – minus any details – at major reforms on conservatorship laws and the Mental Health Services Act. Despite multiple questions from journalists, the Governor only said that we can expect announcements within the next few weeks. “I’m purposely going to obfuscate in terms of the response,” said Newsom, “because we want to lay it out in more detail and specificity and build more understanding, but we are leaning into conservatorships this year.” We will be monitoring activity closely and keep you apprised of any details as they emerge.
Universal Health Care: The governor proposes to expand full-scope Medi-Cal coverage to adults aged 26 through 49, regardless of immigration status, effective no sooner than January 1, 2024 (currently, undocumented immigrants aged 26-49 are ineligible). Anticipated costs are:
- $819 million in Fiscal Year 2023-24
- $2.3 billion ongoing
This proposal is expected to gather much attention, particularly since it crosses the path of the Legislature’s more ambitious, albeit costlier single payer package. When questioned about his opinion of the single payer proposal, Governor Newsom stated that he had not seen the proposal yet.
CalAIM – MEDI-CAL TRANSFORMATION
In 2019, the Department of Health Care Services (DHCS) proposed the California Advancing and Innovating Medi-Cal (CalAIM, the framework for changes to the Medi-Cal program that encompass broad-based delivery system, program, and payment reform. DHCS indicates CalAIM advances several key priorities of the Newsom Administration by leveraging Medicaid as a tool to help address many of the complex challenges facing California’s most vulnerable residents, such as homelessness, behavioral health care access, children with complex medical conditions, the growing number of justice-involved populations who have significant clinical needs, and the growing aging population
Updates to the State’s Section 1115 CalAIM demonstration and Section 1915(b) waiver (which the federal government recently approved), will enable the state to execute the CalAIM initiative, providing benefits to certain high-need, hard-to-reach populations, with the objective of improving health outcomes for Medi-Cal beneficiaries and other low-income individuals in the state.
Taking a whole-system, person-centered approach to health and social care, CalAIM invests about half a billion dollars in state General Funds during calendar year 2022, with increasing amounts over time.
CalAIM initiatives being implemented in 2022-23 include:
- Mandatory enrollment into managed care of beneficiaries eligible for both Medi-Cal and Medicare
- Mandates that all managed care plans cover long-term care
- Targeted set of Medicaid services to eligible justice-involved populations prior to release
- The “Providing Access and Transforming Health” (PATH) initiative, detailed below
Incarcerated individuals leaving correctional facilities are at high risk of poor outcomes due to high rates of mental illness, substance use disorders, complex medical conditions, and potential social needs such as housing insecurity, unemployment, and inadequate social connections. CalAIM proposes to improve outcomes for this population by mandating a county pre-release Medi-Cal application process for incarcerated individuals, allowing Medi-Cal reimbursement for services in the 90-day time period prior to release, and to encourage a facilitated referral and linkage (“warm hand-off”) to behavioral health services, both to providers in managed care networks and to county behavioral health departments.
IMD Waiver: Currently, federal law prohibits states from using Medicaid to pay for care provided in “institutions for mental disease” (IMDs), which are psychiatric hospitals or other residential treatment facilities that have more than 16 beds. This is the only part of federal Medicaid law that prohibits payment for the cost of providing medically necessary care because of the type of illness being treated. This discriminatory exclusion has been in place since Medicaid’s enactment in 1965, and it has resulted in unequal coverage of mental health care.
Recently, states were given the option to cover short-term stays in psychiatric hospitals by applying for a waiver from the federal government, meaning states could receive federal funds for mental services provided to populations with a Serious Mental Illness or Serious Emotional Disturbance (SMI/SED). DHCS plans to submit a proposal to CMS for the SMI/SED Demonstration Waiver in the fall of 2022.
Equity and Practice Transformation Payments: DHCS proposes to make equity and practice transformation payments to qualifying Medi-Cal providers, to close critical health equity gaps; address gaps in preventive, maternity, and behavioral health care measures; and address gaps in care arising out of the COVID-19 Public Health Emergency. These payments are intended to promote patient-centered models of care in pediatric, primary care, obstetrics and gynecology, and behavioral health settings and to align with the goals of the Medi-Cal Comprehensive Quality and Equity Strategy.
CHILDREN & YOUTH
The proposed budget includes the following in FY 2022-23 as part of the Children and Youth Behavioral Health Initiative:
- $87 million to implement Dyadic Services, a model that has been proven to improve access to preventive care for children, rates of immunization completion, coordination of care, child social-emotional health and safety, developmentally appropriate parenting and maternal mental health. In this integrated behavioral care model, pediatric mental health professionals are available to address developmental and behavioral health concerns as soon as they are identified, bypassing the many obstacles families face when referred to offsite behavioral health services. In this model, health care for the child is delivered in the context of the caregiver and family (i.e. “dyadic health care services”) so that families are screened for behavioral health problems, interpersonal safety, tobacco and substance misuse and social determinants of health such as food insecurity and housing instability. Families who are given referrals receive follow-up to make sure they received the services.
- $429 million for evidence-based behavioral health practices.
- $450 million for school behavioral health partnerships and capacity (on top of the $100 million provided for FY 2021-22).
- $230 million for the Behavioral Health Services and Supports Platform and related e-Consult service and provider training (on top of the $10 million that was provided in FY 2021-22).
HOMELESSNESS & HOUSING
Behavioral Health Bridge Housing: While $5.8 billion in last year’s budget for Homekey provided a remarkable investment in long-term housing and services for people experiencing unsheltered homelessness who have serious behavioral health conditions, there is a need for immediate bridge solutions as those new units are built.
The Budget includes an additional $1.5 billion over the next 2 years to address immediate housing and treatment needs, adding 55,000 new homes and treatment beds, and including medication and family supports. Funding will be administered through DHCS’ Behavioral Health Continuum Infrastructure Program and can be used to purchase and install tiny homes and to provide time-limited operational supports in these tiny homes or in other bridge housing settings including existing assisted living settings.
The Administration will develop a strategy that addresses the stabilization and treatment of this extremely vulnerable population of Californians with the most severe and untreated behavioral health conditions. Rather than criminalize the homeless population with behavioral health needs, the strategy will provide community-based care upstream to prevent institutionalization and incarceration.
Behavioral Health Workload: The Budget will add new positions for several critical behavioral health projects in California:
- $350 million to recruit and certify 25,000 new community health workers
- $210 million for social worker training via scholarships and stipends
- $120 million for psychiatric workforce
- 90-day justice-involved in-reach program
- Implementation of the new federal 988 hotline
- New mobile crisis services
- Managing new federal behavioral health grant opportunities
- Intensifying oversight of county behavioral health systems
- Support of the Children’s Crisis Continuum pilot
- Support of the Family First Prevention Services Act.
Felony Incompetent to Stand Trial Waitlist Solutions: California is home to thousands of vulnerable and sick individuals who, because of limited community-based and early intervention treatment, decompensate to a point where engagement and treatment is difficult. For many of these Californians with the most severe behavioral health conditions, they enter into a cycle of untreated mental illness, homelessness, and incarceration. Criminal defendants who are unable to understand criminal proceedings or assist counsel in their defense are determined by a court to be Incompetent to Stand Trial (IST). If these individuals are charged with a felony, they can be committed to the Department of State Hospitals (DSH) to provide clinical and medical services with the goal of restoring their competency and enabling them to return to court to resume their criminal proceedings.
Informed by the deliberations of the IST Solutions Workgroup, which NAMI-CA participated in, the Budget includes spending of $93 million in 2021-22 and $571 million in 2022-23 and ongoing to provide for:
- Early Stabilization and Community Care Coordination to provide immediate solutions to support access to treatment for the nearly 1,700 individuals currently found IST on felony charges and waiting in jail and to reduce the flow of new incoming referrals.
- Expand Diversion and Community-Based Restoration Capacity to increase IST treatment alternatives provided by investing in the community infrastructure required to support the felony IST population.
Medi-Cal Community-Based Mobile Crisis Services: California will add multi-disciplinary mobile response services for behavioral health crises as a new Medi-Cal benefit, as soon as January 1, 2023. The American Rescue Plan Act of 2021 authorizes an 85% federal match for a Medicaid mobile crisis response services benefit, available during a five-year period. Over the five-year period authorized by the Act, total costs of this new benefit are projected to be $1.4 billion. This builds on the $205 million and other funds the 2021 Budget provided to counties for infrastructure development in preparation for the implementation of the mobile crisis benefit.
988 Implementation: NAMI California is a co-sponsor of AB 988, The Miles Hall Lifeline Act, which establishes the “9-8-8” emergency response system for Californians experiencing a mental health crisis.
In 2020, the federal government established “988” as the new three-digit number for mental health crisis hotlines. At the national level, NAMI played a critical role in the federal 988 legislation and mobilized grassroots support to ensure its passage. Once implemented in California, 988 will connect callers with around-the-clock intervention, including mobile crisis support teams staffed by mental health professionals and trained peers. Mental health crisis services and alternatives to calling 911 can be an effective alternative to a law enforcement response, provide an opportunity to effectively co-respond with mental health-law enforcement teams, and divert people with mental illness away from criminal justice system involvement.
NAMI has a long history of partnering with law enforcement, including directly training first responders and promoting standards of justice system policies and practices to make their encounters with people in a mental health crisis effective and safe. NAMI and its national partners have developed many resources to support local communities to start or enhance their crisis intervention programs with first responders. In California, NAMI-CA worked on legislation to improve required training for law enforcement, emergency dispatchers, and other first responders. At the local level, many of our 62 affiliate NAMI-CA chapters work hand-in-hand with local law enforcement and community mental health providers to reduce arrests of our loved ones and address racial justice challenges.
The current mental health crisis response system relies on law enforcement and puts people suffering from mental illness through an expensive and traumatizing revolving-door as they shuttle between jails, emergency rooms, and the street. A comprehensive crisis response system can prevent these tragedies, save money, and increase access to appropriate care. Establishing 988 is an important first step and must be accompanied by new statewide investments that repair holes in community safety nets.
The 2022-23 Budget includes $7.5 million ($6 million ongoing) for the California Governor’s Office of Emergency Services (Cal-OES) to advance implementation of the 9-8-8 call system and support call handling equipment so existing crisis hotline centers have the needed resources to process additional 9-8-8 calls and coordinate and transfer calls with no loss of information between the 9-8-8 and 911 systems.
Opioid Response: In response to the growing problem of increased availability of synthetic opioids and related overdose deaths, the Budget includes $96 million in 2022-23 and $61 million ongoing to expand access to Medication Assisted Treatment. In addition, the Budget includes one-time $86 million opioid settlement funds which will be dedicated to a public awareness campaign targeted towards youth opioids education and awareness and fentanyl risk education ($50 million) and improving the state’s ability to collect and analyze data on opioid overdose trends ($5 million), provider training on opioid treatment ($26 million), and distributing naloxone to homeless service providers ($5 million).