California Lawmakers Approved a Plan To Compel People into Mental Health Treatment. What Comes Next?

[Leroy N. Soetoro]

https://sfstandard.com/criminal-justice/california-lawmakers-approved-
care-court-a-plan-to-compel-people-into-mental-health-treatment-what-
comes-next/

In the next two years, California’s 58 counties will be tasked with
setting up new court systems to address the needs of people with severe
mental illness who often languish on the streets.

Gov. Gavin Newsom’s Community Assistance, Recovery, and Empowerment (CARE)
Court proposal swept through the state Legislature with resounding
approval from Democrats and Republicans in both houses on Aug. 31—only two
of the state’s 120 legislators voted against it—and is expected to be
signed into law by the governor any day. The proposal was authored by
Democratic Sens. Tom Umberg of Garden Grove and Susan Talamantes Eggman of
Stockton through Senate Bill 1338.

Originally, Newsom’s proposal—which would compel people with untreated
schizophrenia and other severe mental illness into housing and
treatment—had a start date of July 1, 2022. But it faced resistance from
county officials who said they were unprepared to create and maintain an
entire legal apparatus, much less provide the necessary services. After
months of successful lobbying to slow down the timeline devised by the
governor and secure more money for planning, the California State
Association of Counties now says it stands ready to help implement the
far-reaching proposal.

Under the new timeline, seven counties will have to establish new courts
by Oct. 1, 2023, followed by the remaining 51 counties in December 2024.
San Francisco is among those pilot counties; others are San Diego, Orange,
Riverside, Stanislaus, Tuolumne and Glenn.

It’s still unclear how the legislation will be implemented in San
Francisco, with a mental health bed shortage posing a potential obstacle
to execution. Members of the court system plan to hold a meeting next week
to discuss next steps but haven’t yet received formal guidance on how to
implement CARE courts, said Melanie Kushnir-Pappalardo, director of the
city’s collaborative court system, in a text.

The system will theoretically work like this: Family, close friends, first
responders and behavioral health workers will be able to submit a petition
to the court, signed under penalty of perjury, on behalf of a person with
untreated schizophrenia spectrum or other psychotic disorders that shows
why they qualify for CARE Court. In order to qualify, the person must be
either unlikely to survive safely without supervision or be a threat to
themselves or others without support. The petition must include either an
affidavit from a licensed health care professional who examined them or
tried to—or proof the person was recently detained under intensive
treatment.

The court would then order a clinical evaluation of the person—and review
the evaluation to see if the person qualifies for CARE Court services. If
they do, they’ll get legal counsel and a “supporter”—an advocate to walk
them through the process, as well as a “Care Plan” that can include
recommended treatment, medication and housing. Medication can be court-
ordered, but not forcibly administered. During 12 months, a participant
will have to attend hearings to make sure they’re adhering to the plan—and
counties are providing the court-ordered services.

Following that year, a person could receive another year of treatment or a
graduation plan, which would not be enforceable by the court. If a person
received the court-mandated services but failed to complete their
treatment, they could be considered by the court for conservatorship,
though refusing medication alone wouldn’t be grounds for failure. The idea
is to make it easier for people who need help, but may not be seeking it,
to get it before they lose legal autonomy or end up in jail.

“CARE Court is a paradigm shift: providing housing and services in the
community, where people can heal—and not behind locked walls of
institutions and prisons,” Newsom said in a statement on Aug. 30.

This is the governor’s latest and boldest strategy to address
homelessness, which consistently ranks at the top of the list of voter
concerns in California—albeit participants don’t have to be unhoused to
qualify. The governor has previously pledged to deal with encampments and
dedicated unprecedented budget funding to the issue. But his
administration concedes this will only serve a small sliver of the 161,000
Californians who were unhoused in 2020—an estimated 7,000 to 12,000 people
a year.

Implementing CARE Courts
Counties now face a series of practical questions critical to turning the
fuzzy concept into a reality: How will unhoused people get to court? What
happens if someone doesn’t show up? Which courts will house CARE Court?
Which judges will preside? Who will conduct the medical evaluations?

There’s about $88 million in this year’s budget to help figure it out. The
counties will get $57 million for startup costs, with $26 million
earmarked for the first seven counties. Farrah McDaid Ting, public affairs
director for the California State Association of Counties, said that money
would go toward everything from cell phones and transportation to setting
up an information sharing system that tracks data on counties’ progress. A
working group for those first seven courts hasn’t yet been pulled
together, she said.

The state Department of Health Care Services, the Health and Human
Services Agency and the Judicial Branch will get another $31 million to
also help set up and coordinate the court system and train staff.

But many of the big questions that swarmed the proposal from the start
still linger— such as whether the necessary housing, mental health
services or workforce would be available, or whether forcing people to
receive treatment is an effective form of help.

The administration’s response to many of these concerns is that there’s
unprecedented funding available through the last two budgets, including
$1.4 billion to support the behavioral health workforce and $14 billion
for housing and clinical residential placements, including $1.5 billion in
bridge housing for which CARE Court participants would be prioritized.

The staggered start should allow the state’s counties to answer some
current unknowns, including how many petitions come in and if housing or
services are available for them, said Michelle Cabrera, executive director
of the County Behavioral Health Directors Association. But with so many
unanswered questions, she said, “even estimating how much staff you’ll
need is a shot in the dark.”

Cabrera anticipates the next few months will be devoted to coming up with
a framework for how the court will look in those seven counties, including
figuring out financing and training and drawing up forms.

Orange County officials don’t expect their new court to represent a
dramatic departure from the status quo—they already operate a drug court
and a mental health court—which is partly why they volunteered to go
first.

“I think the bulk of the people who are going to be referred are not going
to have schizophrenia,” said Veronica Kelley, chief of Mental Health and
Recovery Services at the Orange County Health Care Agency. “We have many
people who are clinically stable, meaning they’re not going to hurt
themselves or others. They can function, but they still might shout at
their voices. They still are experiencing symptoms. So if they are
involved in treatment, they’re clinically stabilized, they don’t qualify
for this.”

Luke Bergmann, director of behavioral health in San Diego County—another
of the first seven counties—says he is especially concerned about the
workforce. He worries about what CARE Court will mean for long-term care,
which is “already under a lot of stress.” He anticipates a substantial
uptick in demand for such facilities, including board-and-care homes,
where serious shortages already exist.

In addition, he says, it is not yet clear who will pay for a lot of the
ongoing operational costs of CARE Court. “We don’t currently have a good
model for how that kind of work should be reimbursed,” he said, especially
for people insured by Medi-Cal.

The state’s Health and Human Services department told CalMatters most CARE
Court participants will be either insured by or eligible for Medi-Cal.
Those with commercial insurance would be required to reimburse the county
for eligible behavioral health care costs. They pointed to nearly $10
billion counties already receive annually for behavioral health care.

Civil rights concerns
Still, advocates worry the court system will backfire.

Eve Garrow, homelessness policy analyst and advocate at the ACLU of
Southern California, which opposes the bill, says people who need help the
most may avoid the mental health system—or even avoid family members who
can file petitions— “because they fear being hauled into court.”

Garrow also fears the number of people funneled into
conservatorships—which restrict far more aspects of a person’s life—will
climb. And she believes Black people will be disproportionately impacted
because they are more likely to be over-policed, experience homelessness
and be misdiagnosed with psychotic disorders.

“The last thing I want to see is a system where, in order to get timely
access to the kinds of resources that you need to survive, you have to
give up all of your rights and be subjected to a court order,” Garrow
said.

In fact, civil rights groups argue the program would “unravel decades of
progress for people with disabilities to have the same civil rights of
everyone else,” said Lili Graham, litigation counsel at Disability Rights
California. Her group says it plans to sue once the law goes into effect.

“We’re outraged,” Graham said. “We’re horrified. We’re ready to file
suit.”

But vehement opposition from similar groups across the country and dozens
of other civil rights groups and homelessness advocates—who are now urging
Newsom to veto his own bill—was not enough to stop it from flying through
both houses.

As legislator after legislator took to the microphone on the penultimate
day of the legislative session, they spoke to a choice between an
imperfect solution and continued inaction.

“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 God awful situation,” said
Assemblymember Al Muratsuchi, a Democrat from Torrance.

“To walk away and say we can’t do anything, to basically say this isn’t
good enough, is to in a perverse kind of way say, ‘We really don’t care,’”
said Assemblymember Jim Patterson, a Republican from Fresno. Patterson
acknowledged casting a vote would not be enough, either.

“This is going to take walking beside these folks, not just today, when we
push the button, but next week, next year, perhaps another decade or so.”



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