Getting Serious About Mental Health
When it comes to healthcare in California, we for far too long have tolerated two different and unequal worlds. I don’t mean rural and urban. I don’t mean rich and poor. While both those dichotomies are true, I am talking about the fundamental differences in our approach to illness of the body and illness of the brain.
In any given year, one in four families in California deal with a mental health condition. An estimated one in 20 adults in the state are living with a serious brain illness. Each year, thousands of young Californians will experience their first psychotic break, enduring the terrifying delusions and hallucinations that are a hallmark of schizophrenia, bipolar disorder and some forms of depression.
We all know someone, don’t we? Whether we’re living with brain illness ourselves, or it’s a spouse, a child, a sibling, a friend. And more often than not we’ve heard about their struggles to find quality care: the long wait times for appointments, and shift to cash-only psychiatrists; the shortage in licensed providers and crisis beds; limited insurance coverage; the punishing side effects of medications; the fear that a boss or colleague or neighbor will learn the truth and look at you differently.
Our system of mental healthcare in California falls short, not for lack of funding. We’ve done the right thing in this state: Thanks to the vision of Sacramento Mayor Darrell Steinberg, we passed a millionaire’s tax in 2004 that now funnels more than $2 billion a year into services. We fall short because we lack the bold leadership and strategic vision necessary to bring the most advanced forms of care to scale across the state. We lack the political will necessary to elevate brain illness as a top-tier priority. We lack the unity and fervor needed to rally the medical and research communities around an unyielding search for ever-better diagnosis and treatment.
We’re all living with the fallout. As a mayor, I was acutely aware of the many ways untreated mental illness tore at the fabric of community. We moved over 12,000 folks off the streets and into housing with supportive services. Yet still, more than 7,500 people live homeless in San Francisco, and research indicates about a third of them are dealing with untreated mental illness. Across the state, 134,000 people are living on the streets, a third of them suffering with progressed stages of mental illness.
One-third of the people living behind bars also deal with a brain illness, making our jails de facto asylums. The Los Angeles County Jail actually doubles as the nation’s largest mental health facility. Students struggle in silence with depression and anxiety. Our suicide rate hasn’t fallen in two decades. Families are ripped apart because they can’t get their children the care they need.
It’s hard to think of a public policy issue not impacted by the state of mental healthcare.
It’s not that we don’t have the answers. We actually know a lot about treating mental illness. We know how to deliver wraparound services on the back end of care that can transform lives. And — more importantly — we know how to deliver intensive services on the front-end, treatment that can stem the course of serious brain illness, including schizophrenia, before it becomes disabling. California has model programs in this arena, as does New York. Australia is a global leader in early diagnosis and intervention. Trieste, in northern Italy, offers a showcase for how to replace a system of substandard institutionalized care with humane and effective services delivered through a network of 24-hour clinics integrated into the community.
What we need is a command structure capable of articulating a clear vision for how we strategically spend our mental health resources, and how we partner with county-level providers to bring the best practices to scale. Even as we respect county-level governance, we need to standardize and scale up some core services so every Californian has access to advanced models of care, regardless of ZIP code. And we need statewide systems for measuring and sharing outcomes.
As Governor, I will pursue an aggressive agenda to lift California’s approach to mental healthcare into a national model.
It starts with leadership: In the 14 years since passage of the Mental Health Services Act, three critical reports have raised questions about the state’s failure to direct and oversee spending. Our statewide delivery system is hampered by confusing and overlapping lines of authority, a lack of clear goals, and uncertainty about who wields the power for enforcement. We lack the centralized authority to ensure our investment is spent effectively, on services with measurable outcomes.
My administration will work with top public policy and research groups to review our delivery system and draw on best practices across the globe to create a more effective leadership structure. Our goal will be a command structure, tailored to California, that has clearly stated objectives and responsibilities, and is vested with the authority necessary to set performance standards, drive strategy for reaching those standards, analyze outcomes, and enforce mandates. We will articulate a strategic vision for care, and provide the support and oversight needed for counties to meet the objectives. We’ll increase our investment in data-collection and analysis, and use these tools to inform our treatment models. We will build on efforts to create public-private partnerships to finance research and technological innovation, with the goal of expanding access to care and advancing our understanding of how to diagnose and treat brain illness.
From Stage 4 to Stage 1: Try to think of another serious illness in this state that we routinely treat at Stage 4? And yet that is the outrageous reality about our approach to mental health treatment. Our system is set up so that the bulk of revenue from the Mental Health Services Act — 80 percent — goes into services for people whose mental illness is already seriously progressed. And just 20 percent goes into early diagnosis, prevention and intervention. UC Davis and UCLA are among the research centers that have developed successful models for intervening in the early stages of mental illness and helping young people not only to live with a brain illness but to thrive — but fewer than half our counties offer such services.
My administration will prioritize prevention and early intervention, and pursue a system of care in which the goal is to identify and intervene in brain illness at Stage 1, just as we do for cancer or heart disease. We will work with our public and private partners, and draw on advances in technology and telemedicine, to create a system in which every young person has access to advanced treatment. Integral to this push, we will launch a campaign to train our teachers, counselors, first responders and pediatricians in how to recognize early signs of mental illness.
Seventy-five percent of serious brain illness manifests before age 25, meaning our college-aged youth are at particular risk. We will work to ensure every public and private college in the state adopts comprehensive strategies for raising awareness of symptoms of mental illness, identifying students at risk, and providing support services. In addition, we will call on every college to implement evidence-based suicide prevention policies.
Integrate and diversify our healthcare workforce: If we’re going to shift the treatment paradigm toward early intervention, we need a more integrated approach to healthcare. That means training primary care doctors — who see the bulk of our patients — in the diagnoses and treatment of minor to moderate brain illness, and how best to refer more serious cases for specialized care. It means creating incentives for provider networks to create collaborative care centers that have the staffing to seamlessly span both brain and body. It means using the powers at our disposal to ensure insurance providers adhere to federal parity rules and adequately compensate for mental healthcare. It means eliminating rules that prevent patients from seeing both primary care and mental health providers on the same day.
America faces a well-documented shortage of psychiatrists that is mirrored in California. Our counties — particularly our rural counties — labor to find psychiatrists willing to work in community health. My administration will tackle this problem head on. We will highlight and grow promising innovations, including expanded roles for nurse practitioners and peer providers. And we will grow the ranks of licensed professionals who elect to work in the community sector through expanded funding for training, scholarships and loan forgiveness.
We will also expand the options available for inpatient care. Since 1995, we’ve witnessed the closure of 44 psychiatric facilities and the 2800 beds that come with them. As hospitals eliminated psychiatric units, the number of acute psychiatric beds per capita fell by 40 percent in California during that time. Rather than lead the nation in this critical aspect of care, we fall well below the national average. My administration will direct both funding and political capital into the effort to revitalize the acute-care system at the community level, pushing through the zoning issues and discrimination that often serve as obstacles to building specialized facilities.
Give law enforcement and courts the training and programs they need: Gaps in our treatment system mean that law enforcement officers are often the first responders for someone experiencing a mental health crisis. Meanwhile, state correctional officers and jail staff are dealing with tens of thousands of inmates who have been diagnosed with mental illness. It’s a reality that can prove debilitating for both law enforcement and the inmates in need of treatment.
Over time, increased investment in early prevention and intervention will help relieve some of this pressure. But we need a more immediate response. My administration will build on existing training for law enforcement officers, dedicating additional resources to instruction in how to de-escalate encounters with people with a mental health issue. We will scale up alternative sentencing options, including successful models of mental health and drug courts. And we will increase resources for specialized mental health units in our prisons and jails, as well as transitional housing that provides support and treatment upon release.
Combat the opioid crisis: The opioid crisis is a mental health crisis. Over 50% of opioid prescriptions are for people with mental illness. Nationally, opioid prescriptions have quadrupled since 1999, as have tragically, opioid-related overdose deaths. Even as the epidemic wreaks havoc on a national scale, California is being hit hard. A more aggressive effort is still needed to combat this overwhelming crisis. We need stricter enforcement of mental health parity laws. We need to curb the eagerness of certain medical providers that write too many prescriptions without fully weighing the consequences. And we need to get more clinicians on the ground and double down on effective treatment and prevention programs.
Bust the stigma: Finally, we will amplify efforts to eliminate the stigma that keeps too many people from reaching out for the care they need. My administration will join efforts to end discrimination in the workplace, encouraging leave policies that mirror those in place for other types of illness and training employers how to accommodate someone living with a brain illness in the workplace so that they have the support they need to live a life with meaning and make a contribution to society. We’ll invest in public service campaigns and outreach to educate our communities and normalize discussion of brain illness.
As Governor, I will embrace the mantra that there is no health without brain health. We will usher in the next era of care, and emerge a stronger, healthier California.
