(The Center Square) – California lawmakers gave the final stamp of approval Wednesday to a bill backed by Gov. Gavin Newsom that provides court-ordered treatment plans and supportive services for people on the schizophrenia spectrum or with psychotic disorders.
The bill, which establishes the Community Assistance, Recovery and Empowerment (CARE) Act, received broad bipartisan support in both chambers of the Legislature, passing in a 62-2 vote in the Assembly and unanimously in the Senate. The bill now heads to Newsom’s desk.
“Today’s passage of the CARE Act means hope for thousands of Californians suffering from severe forms of mental illness who too often languish on our streets without the treatment they desperately need and deserve,” Newsom said in a statement Wednesday.
Backed by cities across the state and strongly opposed by disability rights advocates and the American Civil Liberties Union, the bill would let a person petition for a court-ordered plan that could include behavioral health care, medication, and housing. The petition triggers hearings to develop a treatment plan.
Adults experiencing a severe mental illness like schizophrenia and are either “unlikely to survive safely” without supervision or have a condition that requires support to prevent deterioration could qualify for the program. The CARE plan could last for up to two years, providing services like medication and treatment.
Newsom and others have touted the measure as a way to break the cycle of homelessness and incarceration among people with severe mental problems.
The measure has faced strong opposition from groups within California and across the nation who fear it will result in coerced treatment that would take away a person’s right to make their own care decisions.
Eric Harris, the director of Public Policy with Disability Rights California, told The Center Square Wednesday that the organization still has major concerns about the bill and is “disappointed” in its passage on Wednesday.
“Forced treatment and not providing guaranteed housing is not going to be beneficial to a lot of these people,” Harris said. “We believe that voluntary treatment options that are robust and guarantee accessible, affordable housing is going to bring out the best results and have people who want to engage in this type of process.”
Harris said the bill was constructed without input from a “large number of disability leaders,” noting that leaders at Disability Rights California “weren’t consulted at all.”
The bill received several amendments in its final days in the Legislature, including one that phases in implementation. The counties of Glenn, Orange, Riverside, San Diego, Stanislaus, Tuolumne and the city and county of San Francisco must implement the program by Oct. 1, 2023. The rest of the state has until Dec. 1, 2024.
Other amendments require funding from the Department of Health Care Services and substitute the director of county behavioral health as the petitioner if someone other than the director petitions the court.
As the bill wound its way through the Legislature, lawmakers raised concerns about how the program would be funded and whether counties would have the staffing to handle the program. In the end, the bill won praise from both Democratic and Republican lawmakers for its potential to curb addiction and homelessness.
“This measure, I believe, is the first truly bipartisan attempt to compassionately clear homeless encampments off our streets, sidewalks and highways, to assess the health behavior and needs of homeless individuals and to put together an actual plan to stop the downward spiral that many homeless individuals have so long been on,” Senator Brian Jones, R-Santee, said Wednesday.
Two lawmakers voted against the measure – Assemblymember Ash Kalra and Mark Stone. In a statement sent to The Center Square, Kalra said he could not support the bill because the program has “missing pieces needed for an effective, sustainable solution.”
“While I echo the urgency to find a solution, if we do not couple permanent housing and wraparound services for our unhoused with severe mental illness, we are setting them up for failure,” Kalra said.
Newsom has until Sept. 30 to sign the legislation.
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SACRAMENTO, Calif. (AP) — California Gov. Gavin Newsom’s controversial proposal to steer homeless people with severe mental disorders into treatment cleared the state Assembly on Tuesday and is on its way to becoming law despite objections from civil liberties advocates who fear it will be used to force unhoused residents into care they don’t want.
Homeless people with severe mental health disorders often cycle among the streets, jail and hospitals, with no one entity responsible for their well-being. They can be held against their will at a psychiatric hospital for up to 72 hours. But once stabilized, a person who agrees to continue taking medication and follow up on services must be released.
The bill the state Assembly approved on Tuesday by a 60-2 vote would require counties to set up a special civil court to process petitions brought by family, first responders and others on behalf of an individual diagnosed with specified disorders, such as schizophrenia and other psychiatric disorders.
The court could order a plan lasting up to 12 months, and renewable for another 12 months. An individual facing a criminal charge could avoid punishment by completing a mental health treatment plan. A person who does not agree to a treatment plan could be compelled into it. Newsom has said he hopes these courts catch people before they fall into the criminal court system.
The bill represents a new approach for California to address homelessness, a crisis the state has struggled with for decades. The state government spends billions of dollars on the issue each year, only for the public to perceive little progress on the streets.
“I believe that this bill is an opportunity for us to write a new narrative,” said Assemblymember Mike Gipson, a Democrat who voted for the bill.
The bill has now passed both houses of the state Legislature and needs one more vote in the state Senate before it will go to Newsom’s desk. Newsom has until the end of September to sign it into law.
The proposal had broad support from lawmakers who said it was clear California had to do something about the mental health crisis visible along highways and in city streets. Supporters relayed harrowing tales of watching loved ones cycle in and out of temporary psychiatric holds, without a mechanism to stabilize them in a long-term treatment plan.
Republican Assemblymember Suzette Martinez Valladares said her cousin, a Vietnam War veteran, had been living on the streets in a homeless camp before his death.
“I wish that my family had the tools that this bill is going to bring forward so that he might still be alive and with us,” she said. “This is going to save lives. It’s about time.”
Critics of the legislation have maintained that the state lacks enough homes, treatment beds, outreach workers and therapists to care for those who want help, never mind people compelled to take it. They say that people who choose to accept treatment are much more likely to succeed than those coerced into it.
“At what point does compassion end and our desire to just get people off the streets and out of our public sight begins?” said Assemblymember Al Muratsuchi, a Democrat who said he reluctantly supported the bill on Tuesday. “I don’t think this is a great bill. But it seems to be the best idea that we have at this point to try to improve a godawful situation.”
The bill says Glenn, Orange, Riverside, San Diego, San Francisco, Stanislaus, and Tuolumne counties must establish courts by Oct. 1, 2023, with the remainder by Dec. 1, 2024.
Courts could fine counties up to $1,000 a day for non-compliance, which counties believe is unfair if they don’t have enough support from the state in the way of housing and behavioral health workers.
“There will be no perfect solution to this problem. But this is better than doing nothing and it is too easy in a democracy to kick a problem down the road and do nothing,” said Assemblymember Steve Bennett, a Democrat who voted for the bill.
In early March, Gov. Gavin Newsom unveiled a controversial proposal to compel people with serious mental health issues into care and housing.
Mental health advocates, mayors and family members who stood alongside him at the press conference at a San Jose behavioral health treatment program heralded the plan, known as CARE Court, as a visionary move.
But some county officials say they were stunned.
“They really sprung it on everybody,” said Farah McDaid Ting, public affairs director at the California State Association of Counties, who said lawmakers didn’t consult or even give her organization a heads-up.
Four months later, the bill to establish CARE Court has sailed through all of its policy committees in the Legislature, secured unanimous approval from the Senate in May and is widely expected to become law later this summer. CARE Court — short for Community Assistance, Recovery and Empowerment Court — has garnered enthusiastic support from leaders of more than 45 cities, many of whom face fiery criticism over their handling of homelessness. Many family members, who for decades have felt stymied by strict eligibility rules for conservatorship, are also celebrating the new plan.
But county representatives continue to ring alarm bells about their ability to implement the proposal, especially as an aggressive timeline comes into focus. A handful of counties have registered support for the proposal, including Marin, Contra Costa and San Diego.
Many of the counties’ concerns come in the form of questions: Will the necessary housing be available? Where can they find the outreach workers and therapists needed to serve the population, given massive statewide shortages of both? What happens to all the struggling people who want housing and treatment, and already can’t get it?
Disability rights advocates are raising fundamental questions about the very premise of CARE Court: Is it effective to compel people into care? Is involuntary treatment a violation of their civil rights?
But many of those who support the concept say the practical questions feel especially pressing right now, as the Legislature continues its deliberations. While many details are still in flux, the gist of the proposal remains the same as initially outlined. Anyone from family members to first responders could petition a civil court to create a court-ordered care plan for people who meet specific criteria. These include a diagnosis of schizophrenia or other psychotic disorders, along with being at risk of harming themselves or others or being unlikely to survive on their own. Participants would receive legal counsel and a range of mental health services, medication and supportive housing. Following a series of check-ins during a yearlong period, the participant could either graduate or be referred to an additional year of treatment. If a person refuses to comply, or “fails out”, they could be considered by the court for conservatorship.
Conversations about CARE Court have been peppered with frequent references to people living on California’s sidewalks and under freeway overpasses. But the administration hasn’t been clear about how much of a dent the proposal would make in the state’s massive homelessness crisis. Prior to the pandemic, more than 161,000 people in the state were estimated to be homeless on any given night; that number has likely grown since. The administration says the program will serve 7,000 to 12,000 people with the most acute mental health needs. Homelessness isn’t a prerequisite to participate.
The administration says the proposal represents a crucial step toward addressing one of the state’s great moral and policy failings: the vast ranks of unhoused people languishing with serious mental illness and without care.
“What CARE Court is saying is we must create a pathway wherein these individuals that live in the shadows and often die in the shadows, become a priority group,” said Dr. Mark Ghaly, secretary of the California Health and Human Services Agency, who has been championing the program on behalf of the Newsom administration.
CARE Court’s supporters say no more time can be wasted. Judge Stephen Manley, who started the state’s first mental health court in Santa Clara County nearly 25 years ago, notes the growing percentage of people in local jails and prisons with serious mental illnesses. Only by mandating that counties prioritize this population, he said, will anything change.
“People are always telling me it can’t be done,” he said. “To me it is a tragedy that we repeatedly, year after year after year after year, talk about this issue, do nothing, and all these individuals end up in the criminal justice system.”
Is there enough housing or will there be?
Perhaps the most prominent question that has emerged among legislators and advocates is whether there is enough housing available to get the CARE Court program started.
Short answer: No.
But the state believes that bringing CARE Court participants to the front of the line, along with making unprecedented investments in housing this year, will allow counties to meet the needs of this population. Opponents fear others awaiting voluntary services will be bumped to the back of the line, leaving their needs to intensify.
“I worry if it houses some but leaves others out, are we just reshuffling things?” said Margot Kushel, director of the Benioff Homelessness and Housing Initiative at Zuckerberg San Francisco General Hospital and Trauma Center.
While the new budget deal includes $65 million this year and $49 million in ongoing annual funding to cover training, court costs and legal representation, counties say the proposal doesn’t include any new funding for housing or services.
“There’s a new door being built onto a small house,” Ting said. “There’s no square footage, there’s no nothing, just a new door. That’s what’s kind of frustrating about the premise.”
The administration points skeptics to a $14 billion multi-year homelessness budget put together before the proposal’s announcement — which includes about $5 billion to build thousands of mental health treatment beds and homeless housing. This year’s budget includes $1.5 billion for interim treatment beds to hold patients over while permanent units come online. In response to counties’ concerns that even the bridge beds won’t be ready in time, the bill’s authors recently said counties would be phased into the program over two years, starting in July 2023.
Sen. Susan Talamantes Eggman, the bill’s co-author and a Stockton Democrat, says she believes counties are unhappy with the proposal because it finally holds them to account. It requires that they provide the care and housing a participant needs and if they don’t, face court fines of $1,000 per day. The money, collected by the state treasury, would eventually fund local services for the people CARE Court targets.
“We’re not just saying the person has the obligation to accept, we’re saying the system has the obligation to treat,” Eggman said during a recent hearing.
“I worry if it houses some but leaves others out, are we just reshuffling things?”
ARGOT KUSHEL, DIRECTOR OF THE BENIOFF HOMELESSNESS AND HOUSING INITIATIVE AT ZUCKERBERG SAN FRANCISCO GENERAL HOSPITAL AND TRAUMA CENTER
Counties counter that these penalties will only take away from their already limited resources to treat people.
While the bill says a county has to provide services during the program, courts can’t enforce a participant’s post-graduation plans. Advocates worry that without guaranteed housing people will wind up back on the streets, in emergency rooms and county jails.
“We’re going to release them back into the streets but we expect them to continue to adhere to the care plan and continue to be taking medication,” said Shonique Williams, a statewide organizer for Dignity and Power Now, who opposes the proposal. “But they’re going back into survival mode.”
The state doesn’t keep any sort of waitlist or even a count of treatment beds and housing that’s available to people exiting homelessness. As a result, it’s impossible to gauge the exact shortage in each county.
But a state-commissioned report released in January found that more than 80% of counties need more mental health treatment beds and homeless housing. A 2021 study from the RAND Corporation, a nonprofit think tank,showed the state lacks 5,000 psychiatric hospital beds and another 3,000 beds at residential treatment facilities and board-and-care homes. The shortage is most pronounced in the San Joaquin Valley and for patients with additional medical needs.
“There’s a new door being built onto a small house. There’s no square footage, there’s no nothing, just a new door. That’s what’s kind of frustrating about the premise.”
FARAH MCDAID TING, PUBLIC AFFAIRS DIRECTOR AT THE CALIFORNIA STATE ASSOCIATION OF COUNTIES
Michelle Doty Cabrera, executive director of the California Behavioral Health Directors Association, said one recent survey showed counties had 14,000 unhoused individuals with serious mental illnesses voluntarily participating in full service partnership programs. But they couldn’t find housing for more than half of these individuals, in part because many were screened out for reasons related to their mental health conditions, she said.
In Sacramento County, beds are increasingly rare at board-and-care facilities, where residents receive housing, 24-hour care and three daily meals.
“It is a needle in a haystack right now,” said Terry Fiscus, a behavioral health worker at Turning Point, which contracts with the county.
The less calm and rule-abiding the patient, the less chance they have of getting or keeping a spot, he said. On top of that, facilities have been closing at a rapid clip as housing prices soar and government-set reimbursement rates remain stagnant.
“There are a lot of people that want to come in all the time. We cannot take them,” said Jeanny Leung, who runs a board-and-care home in Sacramento.
“Squeezing blood from a turnip”
Housing isn’t the only big concern counties are raising. To run, CARE Court requires staff and resources.
Some counties say they fear that, without new funding, the program will end up draining resources from other populations, potentially including children and youth.
Cabrera, of the California Behavioral Health Directors Association, uses phrases like “squeezing blood from a turnip” and “robbing Peter to pay Paul.”
“We’re at our limit in terms of what we can do,” she said. “We need more resources to do more.”
The proposal’s proponents argue that there’s plenty of money to get things up and running. They say county mental health systems have had a huge influx of taxpayer dollars in the past two years, thanks to the Mental Health Services Act, a 1% tax on incomes over a million dollars that was enacted in 2004.
“Our millionaires in California seem to be doing very well for themselves,” said Karen Larsen, CEO of The Steinberg Institute, a nonprofit focusing on mental health policy, which supports the proposal. She notes that revenues from the tax have hit historic highs — they were at more than $4 billion this past year.
For two decades prior to assuming her current role, Larsen served as director of Yolo County’s Health and Human Services Agency. She believes counties can afford the costs of the new program.
“If they can prove they don’t have enough resources, I’d love to see it,” she said.
“Many of our people are only stable because we have someone coming twice a day to deliver their meds and check in with them and make sure their furniture is upright.”
PHEBE BELL, NEVADA COUNTY’S BEHAVIORAL HEALTH DIRECTOR
Phebe Bell, Nevada County’s behavioral health director, said she was, indeed, able to tap the influx of Mental Health Services Act funding to purchase a new house, providing beds for six people who were unhoused. But strict rules often limit what that pot of money can be used for, she said.
If the county has to pivot to focus on CARE Court mandates, she worries about who won’t be served.
“Many of our people are only stable because we have someone coming twice a day to deliver their meds and check in with them and make sure their furniture is upright,” she said.
When her county examined their full service partnership program, they found more than a third of the 78 people in their program at any given moment were inadequately housed, with many sleeping on the streets.
“I don’t have a single empty bed in our system of care,” she said. “Who exactly are we incorrectly prioritizing in our work right now?”
Both sides agree on one specific challenge: a massive shortage of mental health providers.
At the beginning of the pandemic, many counties worried they’d face significant shortfalls and preemptively laid off mental health workers.
Now, as need surges, staffing has simply not kept pace. Counties are finding themselves losing bidding wars for therapists being courted by everyone from school districts to telehealth start-ups to major providers like Kaiser. Burnout is driving others from the field entirely.
Some counties now face vacancy rates of 30% to 40% in their behavioral health workforce, and many of the nonprofits they contract with are in the same situation, Larsen said.
“I think it’s the biggest issue we face in mental health and substance use right now,” she said.
This year’s budget includes $1.5 billion to build out the state’s entire healthcare workforce, including hundreds of millions that target behavioral health.
The state’s public guardians and conservators have also eyed the CARE Court proposal warily. While they are not officially affected by the proposal, they say they expect the program could lead to a surge in new referrals.
The programs are already severely underfunded and understaffed, said Scarlet Hughes, executive director of the California State Association of Public Administrators, Public Guardians, and Public Conservators. Right now, caseloads hover at 65 to 85 individuals per caseworker, though in some counties they’re as high as 135. That translates into visiting a client every three or four months, she said.
“Any impact to our members is going to be significant because they’re underwater already,” she said.
Questions over implementation, in addition to the ongoing debate over civil liberties, have been woven through CARE Court’s journey from the start. That hasn’t stopped the Legislature from voting overwhelmingly in the bill’s favor. It is expected to easily clear its final hurdles: an appropriations vote later this summer, a floor-wide vote in the Assembly and a signature from the author, the governor himself.
But despite their ongoing questions, counties have conceded that CARE Court is coming whether they like it or not. They know they’re not likely getting any more money for housing and staffing. For now, they’re using the appropriations process to petition for more time and tools to implement the program.
The administration acknowledges that counties around the state face severe shortages. But it remains committed to the idea of a better way to serve the people who are struggling the most.
“California has done this before,” Ghaly said. “We’ve stepped up for the most vulnerable, the most overlooked many, many times. And we can do it again.”
This story was produced by MindSite News, an independent, nonprofit journalism site focused on mental health.
No es raro que los pronósticos de tormenta generen advertencias de evacuación para las personas sin hogar que viven en el lecho seco del río Santa Ana.
Pero el daño de la tormenta de hace 12 años está obligando a las personas sin hogar a abandonar una parte del lecho del río entre Riverside y Jurupa Valley. Alrededor de 40 personas que se sabe que viven en el área, tendrán que irse antes del domingo 28 de agosto, antes de un proyecto de restauración de diques de $36 millones, dijeron funcionarios del condado de Riverside.
Su desplazamiento preocupa a los defensores de la comunidad de personas sin hogar, que temen más trastornos para las personas que ya están lidiando con la reciente prohibición del Ayuntamiento de Riverside de acampar en el fondo del río.
En su página de Facebook, Inland Empire Harm Reduction, que se describe a sí misma como “una organización de salud pública basada en la comunidad que trabaja para mejorar la salud y el bienestar de las personas afectadas por el consumo de drogas”, expresó su preocupación por los planes para sacar a las personas sin hogar del cauce.
“El condado está avanzando con la construcción a pesar de que hay muchos residentes del fondo del río que todavía están en listas de espera debido a la cantidad insuficiente de camas de refugio en este condado”, se lee en la publicación de Facebook del grupo, y agrega que donó suministros para ayudar a las personas a mudarse, estos “no son una solución a los problemas mucho más profundos que enfrenta este condado”.
Los funcionarios del condado de Riverside dijeron que están trabajando con los afectados para encontrar una vivienda permanente o al menos un nuevo lugar para acampar, y señalaron que no tienen que abandonar el fondo del río por completo. Los equipos de divulgación han estado visitando el área todos los días para informar a los residentes del fondo del río sobre el proyecto y ofrecer ayuda.
“Queremos que estos residentes sientan que estamos reconociendo que les estamos pidiendo que muevan su hogar”, dijo Carrie Harmon, subdirectora del Departamento de Vivienda y Soluciones Laborales del condado. “Estamos totalmente comprometidos a encontrar los servicios y caminos de vivienda que cada individuo está buscando”.
Algunas áreas que viven en la zona de construcción tienen hasta el domingo para mudarse, mientras que otras recibirán avisos para reubicarse a medida que avanza la construcción, dijo la portavoz del condado, Yaoska Machado, por correo electrónico.
ALREDEDOR DE 260 PERSONAS
Serpenteando a través de Riverside y Jurupa Valley en su camino hacia el Océano Pacífico, el fondo del río ha sido durante mucho tiempo un hogar para aquellos que no pueden encontrar refugio en otro lugar. El condado, que realiza recuentos anuales de personas sin hogar, sabe de unas 260 personas que viven en el lecho del río, dijo Harmon.
En los últimos cinco años, el Departamento de Bomberos de Riverside ha combatido 163 incendios forestales en el fondo del río, dos tercios iniciados por personas. Los fuegos a menudo están destinados a cocinar o calentarse, pero a los funcionarios les preocupa que puedan propagarse rápidamente a través de las ráfagas de viento a través del lecho del río completamente seco y amenazar los hogares.
La ordenanza contra los campamentos de Riverside “no está relacionada con el esfuerzo de control de inundaciones del condado”, dijo el portavoz de la ciudad, Phil Pitchford, por correo electrónico. “Es para abordar los incendios y otros problemas de seguridad en esta área sensible”.
Si el consejo lo aprueba en segunda lectura el 6 de septiembre, la ordenanza entrará en vigencia a principios de octubre, agregó Pitchford.
Una serie de tormentas de 2010 dañó las estructuras que protegen los diques al disminuir el flujo de agua, dijo Uhley.
“Si no reparamos estos diques, las futuras tormentas seguirán trabajando en ellos y los erosionarán y, en última instancia, podrían provocar fallas”, agregó. “Así que este es absolutamente un proyecto de seguridad pública”.