In November 2004, voters in the U.S. state of California passed Proposition 63, the Mental Health Services Act (MHSA), which has been designed to expand and transform California's county mental health service systems. The MHSA is funded by imposing an additional one percent tax on individual, but not corporate, taxable income in excess of one million dollars. In becoming law in January 2005, the MHSA represents the latest in a Californian legislative movement, begun in the 1990s, to provide better coordinated and more comprehensive care to those with serious mental illness, particularly in underserved populations. Its claim of successes thus far, such as with the development of innovative and integrated Full Service Partnerships (FSPs), are not without detractors who highlight many problems but especially a lack of oversight, large amount of unspent funds, poor transparency, lack of engagement in some communities, and a lack of adherence to required reporting as challenges MHSA implementation must overcome to fulfill the law's widely touted potential.

Background

At one time, California was known for having a strong mental health system. Treatment was available for Medi-Cal recipients with few limitations on care. Legislators and voters have acknowledged the inadequacy of California's historically underfunded mental health system to care for the state's residents, especially those with serious mental illness, over the past few decades. In 1991, to build a more community- and county-based system of care, the California legislature instituted realignment, a delegation of the control over mental health funds and care delivery from state to county. This was followed by a succession of legislation targeted towards marginalized populations with high documented rates of mental illness, such as the homeless (AB 2034, in 1999) and the potentially violent mentally ill (Laura's Law, in 2002).

However, with the passage of Proposition 63 in 2004, California voters acted upon a widespread perception that state and county mental health systems were still in disrepair, underfunded, and requiring a systematic, organizational overhaul. This perception echoed a nationwide perspective, with the President's New Freedom Commission on Mental Health in 2003 calling for fundamental transformation of the historically fragmented mental health system. The MHSA is California's attempt to lead the way in accomplishing such systemic reform.

In the end, voter consciences were pricked by the well-organized and -funded campaign that displayed both the need (50,000 mentally ill homeless people, according to the National Alliance on Mental Illness) and the promise (successes of past mental health initiatives) of increased funding for the mental health system. Then-Assemblyman Darrell Steinberg and Rusty Selix, executive director of the Mental Health Association in California, led the initiative by collecting at minimum 373,816 signatures, along with financial ($4.3 million) and vocal support from stakeholders. Though Governor Arnold Schwarzenegger and the business community were opposed to Proposition 63 because of the tax it would impose on millionaires, the opposition raised only $17,500. provides for developing, through an extensive stakeholder process, a comprehensive approach to providing community based mental health services and supports for California residents. Approximately 51,000 taxpayers in California will be helping to fund the MHSA through an estimated $750 million in tax revenue during fiscal year 2005–06.

The MHSA was an unprecedented piece of legislation in California for several reasons:

  • Its funding source, quantity, and allocation is dedicated for mental health services, including times of budget cuts to many other public programs
  • It was intended to engage communities in prioritizing which service elements would be funded.
  • It was focused on developing preventive and innovative programs to help transform the mental health care system in California.

To accomplish its objectives, the MHSA applies a specific portion of its funds to each of six system-building components:

  • Community program planning and administration (10%)
  • Community services and supports (45%)
  • Capital (buildings) and information technology (IT) (10%)
  • Education and training (human resources) (10%)
  • Prevention and early intervention (20%)
  • Innovation (5%)

Notably, none of the funds were to be used for programs with existing fund allocations, unless it was for a new element or expansion in those existing programs. At least 51% of the funds have to be spent on community services and support for children and adults with or at risk of developing mental illness.

Roles and responsibilities

While the county mental health departments are involved in the actual implementation of MHSA programs, the MHSA mandates that several entities support or oversee the counties. These include the State Department of Mental Health (DMH) and the Mental Health Services Oversight and Accountability Commission (MHSOAC).

California State Department of Mental Health (DMH)

In accordance with realignment, the DMH approves county three-year implementation plans, upon comment from the MHSOAC, - whether it is housing, "integrated services, flexible funding [such as for childcare], intensive case management, [or] 24 h access to care." But the FSP model looks more like that of the also-popular MHA Village in Long Beach, which is a center that offers more comprehensive services besides those specifically mental health-related. Beyond these guiding principles, however, there has not been much consensus over unifying strategies to define and implement an FSP - resulting in varying FSP structures across counties.

Continued challenges

According to the UCLA Center for Health Policy Research, the 2007 and 2009 California Health Interview Surveys (CHIS) demonstrate continued mental health needs of almost two million Californians, about half of which were unmet in 2011. In spite of steady tax revenue ($7.4 billion raised as of September 2011) earmarked for the MHSA, the unremittingly high numbers of mentally ill who lack treatment contrast starkly with the implementation of new programs like the FSPs, which may cost tens of thousands of dollars annually per person. The MHA Village program, for example, averages around $18,000 annually per person. tags which will then appear here automatically -->

Government agencies

  • CAIChildLaw.org - 'Sacramento County Funding Request for Mental Health Services Act Community Planning Program'
  • www.dmh.ca.gov - 'Mental Health Services Act (MHSA): Home Page', California Department of Mental Health
  • www.mhsoac.ca.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)

Private Organizations

  • CDCan.us - 'California Disability Community Action Network: Linking People to Disability Rights and Issues'

Media coverage

  • CaliforniaHealthline.org - 'County Officials Work To Create Plans for Allocation of Proposition 63 Funds', California Healthcare Foundation (July 11, 2005)
  • ContraCostaTimes.com - 'Mental health funding offers hope', Sara Steffens, Contra Costa Times (July 11, 2005)