Field looks to emulate success of California's Prop. 63

Field looks to emulate success of California's Prop. 63

Mental Health Weekly January 10, 2005

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A lot of mental health professionals are "California dreaming" as 2005 begins, and not because the winter days have set in. The cause for the reverie stems from an innovative ballot measure passed in November by voters of the Golden State that creates a new revenue source of at least $1 billion a year to redesign the state's mental health system for children and adults.

Proposition 63, or the Mental Health Services Act, establishes a 1 percent tax on the state's wealthiest residents, those with personal income over $1 million, to expand mental health programs and services, including prevention, early intervention, education and training programs.

The initiative, which passed with 54.5 percent of the vote, also prohibits the state from decreasing funding levels for mental health services below current levels. In a field hungry for its fill of resources, the passage of Proposition 63 stands as a gleaming cornucopia. The quip is that planeloads of mental health professionals, researchers and administrators will be flocking to the state in the coming year in a kind of mental health "gold rush."

How the results of Proposition 63 will pan out remains to be seen; the laborious, detail-oriented task of devising the rules for spending the new money will take months to complete. For many mental health leaders and professionals across the country, the more immediate questions are: How did California's mental health advocates and policymakers accomplish their groundbreaking achievement, and can it be done elsewhere?

"A lot of people are paying attention," says Rusty Selix, executive director of the California Council of Community Mental Health Agencies. Selix also was executive director of the Campaign for Mental Health, the coalition that wrote and supported Proposition 63.

Already, representatives of the National Association of State Mental Health Program Directors (NASMHPD) and the National Council for Community Behavioral Healthcare (NCCBH) have met with or have planned meetings with the initiative's principal architects.

Bill Emmet, coordinator of the Campaign for Mental Health Reform, a national coalition that includes NASMHPD and NCCBH, says that the coalition will analyze and try to leverage California's experience on a broader scale, though it would be "nothing as simplistic as saying we can do the same thing on a national basis."

One approach, Emmet says, might be to carry to members of Congress the message sent by California voters: That "people recognize there need to be drastic improvements in mental health "service delivery."

Linda Rosenberg, chief executive officer of NCCBH, this month has scheduled conference calls with members from some interested states to learn about California's experience, and there are plans to put out a "how-to" guide and to make technical assistance available, she says. As well, Proposition 63's architects and key supporters, including Selix, former California Assemblyman Darrell Steinberg and state Mental Health Director Stephen W. Mayberg, Ph.D., will be among the speakers at NCCBH's annual conference in March in San Francisco.

The success in California stemmed from several factors. There was public support for addressing mental health issues; a history of some lawmakers, regulators and advocates working together to produce seminal mental health projects; and a referendum process, income tax reporting requirements and other state policies that made the effort possible. There also were people like Selix, whom his colleagues describe as optimistic, methodical and savvy about maneuvering through political and public regulatory systems.

Proposition 63 partly emerged from California's strapped financial situation and the policies that govern its ability to raise taxes. Given the budget deficits of recent years, and that raising taxes requires a two thirds vote of the state legislature, it was unlikely that lawmakers would approve spending significantly more for mental health.

The measure also was rooted in the success of the so-called AB 34 programs that California pioneered in three counties in 1999. Named after the state Assembly bill that later authorized their expansion, the projects are in at least 38 counties. They serve homeless people, parolees and probationers with serious and persistent mental illness, using aggressive outreach and a "whatever-it-takes approach" to match services to client needs. The programs have saved millions of dollars by cutting down on hospitalization and incarceration costs. The President's New Freedom Commission on Mental Health in 2003 listed the AB 34 projects as model programs, citing their funding flexibility, accountability and menu of services.

Two years ago, the California mental health coalition formed focus groups and conducted polling as it sought to ascertain voters' attitudes and beliefs around how public money should be raised and spent, and about people with mental illnesses. The research showed that ordinary citizens would support by a 3-to-1 margin a ballot initiative to provide comprehensive services to people with a disabling mental illness.

The consultants also tested 10 funding schemes to pay for such services; the one to add a surtax to the income of the state's richest residents was "far and away the most acceptable to voters," says Bill Zimmerman, a partner in Zimmerman & Markman in Santa Monica who worked on Proposition 63 and has extensive experience working on voter referendums. (In an unrelated survey in Connecticut late last year, 77 percent of people polled favored a millionaire's tax, including 63 percent of Republicans, 86 percent of Democrats and 80 percent of unaffiliated voters, according to a report in the Hartford Courant.)

The November vote in California echoed the smaller-scale opinion gauging efforts there. The referendum results, Selix says, suggest that "there is broad public understanding that we don't have adequate mental health services and the public wishes we did."

The initiative's drafters arrived at the added tax rate of 1 percent based on calculations from the AB 34 programs, including costs and the numbers of people served. California has some 50,000 homeless adults with untreated mental illness, and another 50,000 adults disabled with mental illness who need comprehensive treatment.

The act would extend services to about 50,000 more adults at any given time, according to Selix. The need among children is harder to estimate, though the numbers are smaller. In other states, Zimmerman says, the additional tax rate could be different, perhaps a half percent or 1.5 percent, depending on local needs.

Opposition to the California ballot initiative came from taxpayer groups led by the Howard Jarvis Taxpayer Association and by the Church of Scientology, Zimmerman says. Of the coalition's $2 million advertising budget, about $800,000 was spent countering the efforts of those two groups.

Noting that the campaign's total $4.5 million budget was "very similar to Proposition 36 in terms of overall budget and how it was spent," Zimmerman says that major donations came from the coalition; the California Healthcare Association; the Service Employees International Union and the American Federation of State, County and Municipal Employees; and from individuals and families. The coalition set up a website more than 15 months before the election with instructions for donating money. (The nearer to election day, the greater the cost of obtaining voters' signatures and of the overall campaign, Zimmerman notes.)

Whether an initiative might succeed elsewhere also depends on residents' context for considering mental health issues. "California closed mental hospitals one day and the next there were huge numbers of homeless people. The connection was made and remembered," Zimmerman says. "t played an important role in shaping public opinion. The number of homeless people on the streets likely correlates with the amount of sympathy people have," he adds.

The California focus groups revealed that motivation also increased in the context of asking about preventing emotional disorders among children, and intervening early in their young lives.

Combine children's and homeless issues, and the focus group participants "felt bad about it; wasn't a top political concern they had but it was something they had a great deal of concern for," Zimmerman says. Success also depends on the type of election, whether primary or general elections and the levels of public office being sought, as well as the candidate races and the state's political makeup.

Finally, it is critical that the initiative is carefully drafted to be clear about how the money is to be raised and spent, Zimmerman says.

"Maybe California will become a model," he says. "There are always growing pains, we clearly have seen that with Proposition 36, but we've turned a corner. [With Proposition 63], we're funded to do a lot of work that wasn't available before and the challenge now is to do that well."

Selix says the immediate task in California is to identify the programs and services that work, "the things we do right." Emphasis initially will be on workforce development, facility capacity and "getting everybody on the same page on getting toward the vision," he says. The goal is to spell out at the county level rules for services by April, then pass the drafts along to the state for review.

Initial changes could be implemented as early as October, Selix says. Meanwhile, people already using services and people entering the system must continue to be served, Selix says. And advocates need to watch their flanks, protecting existing funding of $3 billion to $4 billion.

The new money, which will increase community-based services by 20 percent to 50 percent, "is only enough if we hold on to what we have. We're not foolish enough to assume that'l be an automatic thing," Selix says.

"We're building a whole new mental health system. We're not just adding money. We're transforming a system to a let's-do-it-right system, based on a lot of prevention and early intervention work," he says. "It's so different from where we are now. It's very exciting and very daunting, the task that's ahead of us."

Few would doubt that statement. Says NCCBH's Rosenberg: "We're very proud of Rusty and the providers. They drove the agenda, together with a strong mental health commissioner. Now the hard part is making it work in an incremental way when everybody wants some of the action."

To read more about & Markman consultants, www.Zimark.com.

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Could a Proposition 63 succeed in another state?

Bill Zimmerman, a partner in Zimmerman & Markman thinks so. In fact, Oregon is _ready to roll_ on preparing a ballot measure, says the consultant, who has extensive experience with voter referendums involving drug-policy reform in several states, including California_s successful diversion-to-treatment initiative, Proposition 36, which voters passed in 2000. Zimmerman & Markman also created MoveOn.org, the campaign designed to help defeat President Bush last November.

The easiest states for a mental health referendum to take hold in are those in which two criteria can be met: states must have a ballot initiative process and, to identify people who earn more than $1 million, a graduated income tax. Colorado and Michigan, for example, have a flat tax, and Washington and Florida have no income tax, Zimmerman says.

The states that meet both criteria are Arizona, Arkansas, Idaho, Maine, Mississippi, Missouri, Montana, Nebraska, North Dakota, Ohio, Oklahoma, Oregon and Utah, Zimmerman says. The effort still may be possible in other states, he says. In some, such as Colorado, Massachusetts and Michigan, there may be ways of determining high income-earners other than through the graduated income tax; it will take further research to ascertain that, Zimmerman says.

The "genius" of California's approach, he says, is that "rich people aren't organized." Trying to raise alcohol or tobacco taxes as a source of added revenue comes up against opposition from powerful, organized lobbying groups. But "people who make more than $1 million aren't organized," says Zimmerman, who says he would welcome the chance to run another initiative campaign in another state.

He also notes that many people earning more than $1 million expressed support for the measure. And, accounting for a 3.5 percent federal tax cut, that group came out ahead, even with the 1 percent state tax added, Zimmerman observes.

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Last Updated on 01/10/05 webmaster@namiscc.org

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