Doing ‘whatever it takes’

State Senate President Pro Tem Darrell Steinberg’s Capitol office is, in a word, gigantic—more like a living room than an office. A desk here, a sitting area with couches there, some work stations against the wall. This is clearly a room where more than one thing goes on at once, where important stuff happens.

Room 200 says a lot about its current tenant—the focus should be on the happening stuff, not the man.

Steinberg is, in many ways, an unusual choice to head up the California Senate. He is from Sacramento, not Los Angeles or San Francisco, where there are more people and more campaign dollars.

Well-liked and knowledgeable, Steinberg has been the author of many pieces of legislation that have significantly improved the operations of government. But his signature achievement is Proposition 63, the Mental Health Services Act, which put an extra 1 percent tax on Californians earning more than a million dollars, raising $1 billion per year for mental-health services in the state.

As a member of the Sacramento City Council in the 1990s, Steinberg became acutely aware that many mentally ill people were not getting the help they needed and were ending up living on the streets. When he was elected to the Assembly in 1998, he decided to make mental illness and homelessness his cause.

His first effort was Assembly Bill 34, which allocated $10 million to set up pilot programs in Sacramento, Los Angeles and Stanislaus counties. The programs enrolled 1,000 people in “integrated services” programs that sought to provide “whatever it took”—housing, mental-health and substance-abuse treatment, vocational assistance—to get mentally ill people back on their feet.

It was the first time such an inclusive approach was tried, and it was so successful that the next year it was allocated $55 million.

In 2003, seeking to expand this “full-service partnership model” by adding strong prevention, early intervention and innovation elements, Steinberg and his allies in the mental-health-treatment field wrote Proposition 63.

With health experts and agencies readying for the 2014 rollout of the national Affordable Care Act, now seemed a good time to begin a broad-ranging discussion with Steinberg about the achievements of Prop. 63, the future of mental-health services in California, and how it all ties into the implementation of health-care reform.

It’s just the kind of far-reaching subject you might expect to hear discussed by a politician whose base of operation looks as expansive as Room 200.

The following is an edited version of our conversation.

So Prop. 63 passed in November 2004…

I raised the minimum amount of money necessary to go one week on TV, and we won, not overwhelmingly but with 53 percent of the vote.

[One] reason we won was because this is an issue that affects everybody. Everybody knows somebody. As I campaigned around the state, the stories from people from all walks of life, all socioeconomic categories, all races and ethnicities, genders … everybody knows somebody with mental illness. So this thing touched a chord.

The beauty of the Mental Health Services Act is that it’s not a one-time shot of money or one-time pilot. It repeats—the funding repeats itself every year. As great as this is now, it’s going to be even more significant a decade from now, 20 years from now.

When that $1 billion came into the system, it created a frenzy of different people wanting to get funding. Let’s talk about that process and what you’ve learned.

The mental-health community—which is large and diverse and includes clients themselves who are very, very active—have felt excluded from the political process. And no one really expected that this opportunity would arise. Because for years what they dealt with were diminished funding, budget cuts and not much attention paid to this issue.

One of the things we’ve said from the beginning is that it shouldn’t be just a top-down decision as to how these funds are actually invested—the community and the clients need to be involved. There’s an estimate that, at one time, we had 100,000 people involved around the state in various stakeholder meetings to determine the act’s priorities. The first round of funding was a little bit slow as everyone sort of adjusted to this gift, really, and how to properly invest it.

Once everything got off the ground it worked. I know 25,000 people have now benefited from full-service partnerships. … The counties are where to invest the money. Some are investing in the more traditionally homeless mentally ill population, some are focused on the ethnic communities that have been underserved for a long period of time, and some are investing in transition-age foster youth with serious mental illnesses. The counties are all defining how they want to spend the funds.

You’ve said the “whatever it takes” approach has been successful from early on. Do you mean in specific outcomes? And in reducing other kinds of expenses?

Yes. We saw reduced hospitalization, days of homelessness and jail time. Those are three major indicators. You know, with politicians it’s become a bit of a cliché that an ounce of prevention is worth a pound of cure. There is no question.

One of the things we did earlier … was we toured the county jail systems, which were renowned for being the biggest mental-health program in California. I mean, even conservatives were writing about the fact that we had criminalized the mentally ill in California, because the only place for anybody to get help was to get arrested, or to get in some kind of trouble, or find themselves on the street.

The philosophy behind … Prop. 63 has always been about early intervention and case management. That means having one stop where someone can get the help they need and regain their lives.

Some people say that, especially at first, there was a very cumbersome process in terms of allocating the Prop. 63 money. True?

Yeah, well, we were very concerned that if we were going to ask the public for this kind of money—and of course it was from million-dollar earners but still public money—that there be a real emphasis on accountability for the dollars. So we set up a process that had the counties, the state Department of Mental Health and an oversight and accountability commission as sort of co-equal partners in checking and balancing one another.

What we found in the first round is that the grant applications were just too cumbersome and it was taking too long to get the money out. So what we’ve done is essentially gotten the state out of the application-review process. The focus of the state is now on evaluations and outcomes. Counties are much happier now, because the money is flowing a lot easier.

The other thing is, I wanted the money to go to counties, but I also wanted there to be a statewide focus on a couple of key issues. And that includes housing. I think there’s been a recognition that if we are really going to end or significantly reduce homelessness, supportive housing has got to be a lead strategy. If somebody is not in a safe place, all of the array of services will often go unused because the person is out on the street.

So getting housing for homeless people with mental illness is key?

Yes. My push was to set $400 million aside for permanent supportive housing for people living with mental illness. And in a number of different instances that money is not the exclusive financing for housing, but it’s a major catalyst where units have been set aside for people living with mental illness. It’s not segregating them; it’s all integrated within a community.

Right now we are at 1,800 [units] that are actually built and up and running. And more to come. If you think about it, 1,800 units—that’s 1,800 fewer homeless people on the streets. Obviously, though, there’s a lot more to do there. …

We are also taking a statewide approach to suicide reduction, prevention and student-mental-health services where we now have programs in all three public-university systems to enhance their ability to provide help to young people. The college campuses are often where the first signs of schizophrenia turn up.

Prop. 63 requires that much of the funding go to new services. That’s caused some controversy, right?

Well, this has been another challenge—the idea is that the money cannot be used to supplant. In other words, we didn’t want this new pot of money to come forward and have the state and counties then take the same amount out of their core system intentionally, leaving us with the same amount of money. …

But what’s happened is … the bottom has dropped out on state and county finances. So, we’ve had this odd situation where the core system is being reduced while the whatever-it-takes and prevention system is kicking in.

Some have complained that some people are getting the Cadillac while the Hyundai is no longer working. Of course, I reject that. Because what we are attempting to do, and what we are doing slowly, is building one system. And it’s one system that is premised on a very different and better philosophy, which is recovery—doing whatever it takes, which is not just having people cycle in and out of clinics or in and out of institutional care and hospitals.

To put the question a different way, given what has happened to the core system, where would mental-health services be today without the Mental Health Services Act? I mean, it would be horrible, because there would be so much less.

So there are some challenges because we are trying to integrate an old system and a new system in a time where one pot of money is increasing and another is decreasing. But we are trying to integrate them; the goal is one system.

You mentioned earlier how we’ve learned that people who are prone to schizophrenia generally have their first episode sometime in their late teens or early 20s. With early intervention and prevention, how much do you think we can actually reduce mental illness in California?

Well, it’s earlier than college, even. For example, at the MIND Institute at the University of California at Davis, they’re doing a lot of research on some of the indicators for early onset schizophrenia. And it’s evolving, but they believe that as early as age 13 or 14—with the right kind of awareness and education—parents and pediatricians and school officials can know, or at least have some sort of suspicion, that a young person needs intervention.

If we have the resources, over time we may not be able to absolutely prevent the onset of a biologically based, chemically based illness, but we can do a whole lot more to make sure it’s manageable. And then individuals can get the support they need to lead a regular life. That’s the goal. Mental illness does not have to be a life sentence of homelessness, hopelessness. It does not have to be.

What does the Mental Health Services Act do to address the stigma that’s often attached to mental illness?

Well, the act was really premised on what we call “attaining cultural competency.” A lot of attention is now being paid to how best to serve the diverse communities of California. … There is stigma in the general society, and sometimes an even deeper stigma in [certain] communities, and so it’s a challenge how to approach and how to help people living with mental illness.

In Sacramento County, for instance, some of the monies are going directly to multicultural centers that are focused on those sorts of outreach. … There’s also a real focus on the resources being spent in a client-centered way. In other words, it’s not about this is what we are going to do for you, because recovery is about the person living with mental illness being part of their own recovery. … There needs to be a whole lot more work on educating people on what those signs are so they can either get help for themselves or help a friend or help a family member.

I’ve heard that 5 percent of Medi-Cal recipients use about 50 percent of total expenditures. And that about half of those expenditures involve some mental-health issue. Are we in the ballpark there?

It’s probably not far off. We’ve done some work here in Sacramento on the emergency-room crisis and the fact that the emergency rooms are impacted by [the mental-health issue]. The police bring somebody to the emergency room, then the emergency room has to figure out how to treat the person.

Just like the county jails, the emergency room shouldn’t be the primary place where people are referred for mental-health care. But that’s because we haven’t had an act like this before, with its focus on outreach, case management and whatever it takes.

How will the federal Affordable Care Act, which includes mental-health coverage, affect Proposition 63, with its emphasis on early intervention and prevention?

Proposition 63 passed in 2004. It was way ahead of its time with its emphasis on early intervention and prevention. Both the Mental Health Services Act and the Affordable Care Act are very compatible working on similar principles. The real push in the Affordable [Care] Act is the creation of a medical home model.

This is where each patient would have a medical home where many of their health needs were met, such as mental health, physical therapy and primary care. There would be different medical homes or community clinics that have different emphases.

What’s the end result of combining Prop. 63 and the Affordable Care Act?

To help people get healthy without the experience of a dramatic life event or more serious illness is the goal. It is one of the primary goals of the Affordable Care Act, and it is the primary goal of the Mental Health Services Act.