California Mental Health Services Act
On 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 on 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. On November 2, 2004, Proposition 63 passed with 53.8 % of the vote, with 6,183,119 voting for and 5,330,052 voting against the bill. Overview. The voter-approved MHSA initiative 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: To accomplish its objectives, the MHSA applies a specific portion of its funds to each of six system-building  components: 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. The MHSA stipulates that the California State Department of Mental Health (DMH) will contract with county mental health departments (plus two cities) to develop and manage the implementation of its provisions. Oversight responsibility for MHSA implementation was handed over to the sixteen member Mental  Health Services Oversight and Accountability Commission (MHSOAC) on July 7, 2005, when the commission first met. The MHSA specifies requirements for service delivery and supports for children, youths, adults and older adults with serious emotional disturbances and/or severe mental illnesses. MHSA funding will be made annually to counties to: Implementation. Starting from enactment, implementation of the MHSA was intended to take six months; in reality, the process of obtaining stakeholder input for administrative rules extended this period by several months. By August 2005, 12 meetings and 13 conference calls involving stakeholders across the state resulted in the final draft of  rules by which counties would submit their three-year plans for approval. Counties are required to develop their own three-year plan, consistent with the requirements outlined in the act, in order to receive funding under the MHSA. Counties are obliged to collaborate with citizens and stakeholders to develop plans that will accomplish desired results through the meaningful use of time and capabilities, including things such as employment, vocational training, education, and social and community activities. Also required will be annual updates by the counties, along with a public review process. County proposals will be evaluated for their contribution to  achieving the following goals: MHSA specifies three stages of local funding, to fulfill initial plans, three year plans, and long term strategies. No services would be funded in the first year of implementation. The DMH approved the first county plan in January 2006. Allocations for each category of funding were planned to be granted annually, based upon detailed plans with prior approval. However, an amendment to the MHSA, AB 100, which passed in March 2011, serves to streamline the DMH approval and feedback process to the counties, ostensibly to relieve the DMH of some of its administrative burden. Roles & 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, and passes programmatic responsibilities to the counties. In the first few months immediately following its passage, the DMH has: The DMH has directed all counties to develop plans incorporating five essential  concepts: The DMH, in assuming and asserting its primacy over MHSA implementation, has dictated requirements for service delivery and supports as follows: Mental Health Services Oversight and Accountability Commission (MHSOAC). The authors of the MHSA created the MHSOAC to reflect the consumer-oriented focus of the law, mandating at least two appointees with severe mental illness, two other family members of individuals with severe mental illness, and various other community representatives. This diverse commission holds the responsibility of approving county implementation plans, helping develop mental illness stigma-relieving strategies, and recommending service delivery improvements to the state on an as -needed basis. Whenever the commission identifies a critical issue related to the performance of a county mental health program, it may refer the issue to the DMH. The first meeting of the MHSOAC was held July 7, 2005, at which time Proposition 63 author Darrell Steinberg was selected unanimously by fellow commissioners as chairman, without comment or discussion. After accepting the gavel, Steinberg was roundly praised for devising Proposition 63's 'creative financing' scheme. Steinberg then said, "We must focus on the big picture," and stated his priorities with regard to the implementation of the MHSA: MHSOAC commissioners. In accordance  with MHSA requirements, the Commission shall consist of 16 voting members as follows: State government appointees. The initial government officials and designee appointed: Governor's appointees. On June 21, 2005, Governor Schwarzenegger announced his appointment of twelve appointees to the MHSOAC: Current progress. One unqualified success story from the MHSA thus far involves the implementation of Full Service Partnerships (FSPs) demonstrating the "whatever it takes" commitment to assist in individualized recovery - whether it is housing, "integrated services, flexible funding [such as for childcare], intensive case management, [or] 24 h access to care." FSP interventions are based upon evidence from such  programs as Assertive community treatment (ACT), which has effectively reduced homelessness and hospitalizations while bettering outcomes. 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. Overall, though, the Petris Center, funded by the DMH and California HealthCare Foundation to evaluate the MHSA, has reported quantifiable improvements in many areas: 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 . One of the major growing concerns regarding MHSA implementation is its unintentional but worrying tendency to create silos of care. As directed by the DMH, counties search for "unserved" mentally ill or at-risk individuals to enroll in their new programs, while keeping existing and perhaps underserved clients in old programs that are usually underfunded, but cannot take MHSA funds. Ironically, while the MHSA was established in part to address racial/ethnic disparities in health care, it may be perpetuating the disparity in services delivery between underfunded and well-funded, new programs. A possible solution to this issue highlights  another challenge for the MHSA: the need for more comprehensive evaluation, oversight, and advisory mechanisms. Though there is an accountability commission, the MHSOAC, its oversight and regulatory responsibilities are not well-defined. However, it is a relatively new entity, having been created by the MHSA in 2004, and has yet to fully delineate its role in the MHSA. With time, the MHSOAC will hopefully continue to develop towards its stated function. Objective and expert evaluation of the MHSA will also be necessary to achieve the kind of longstanding system-wide improvement that then becomes a model for others. California Mental