Existing law, the Mental Health Services Act (MHSA), an initiative measure enacted by the voters as Proposition 63 at the November 2, 2004, statewide general election, establishes the Mental Health Services Oversight and Accountability Commission to oversee the administration of various parts of the act. The MHSA permits amendment by the Legislature by a 2/3 vote of each house if the amendment is consistent with, and furthers the intent of, the MHSA.

In addition to its existing duties, this This bill would require the commission, on or before January 1, 2020, to establish 5 statewide objectives for the treatment and prevention of mental illness prevention, early intervention, and treatment of mental illness, the promotion of mental health and well-being, and innovation as a strategy for transformational change, and metrics by which progress toward each of those objectives may be measured. The bill would require the commission to work with appropriate stakeholders in establishing these objectives and metrics. The bill would require the obejectives and metrics to be reviewed at least every 5 years and, if appropriate, revised. The bill would prohibit the commission from using MHSA funding to carry out these additional duties. establish strategies to collect, analyze, and monitor the established metrics and for technical assistance, support, and evaluation to support the successful implementation of these provisions. The bill would require the commission to review specified existing requirements and other oversight and accountability efforts to see if the commission can streamline those requirements, and, periodically, but at least once every 5 years, to review the established objectives, metrics, and strategies. The bill would require the commission to work with appropriate stakeholders, subject matter experts, counties, providers, state officials, and others the commission deems necessary in implementing these provisions.

The bill, beginning January 1, 2021, would require all counties to annually submit a report to the commission and the Legislature, by the end of each fiscal year, that documents its progress toward the statewide objectives, using the metrics described above. The bill would also require each county to document specified mental health funding allocations in relation to the statewide objectives. The bill would prohibit counties from encumbering MHSA funding for purposes of complying with these provisions. objectives, or, if the county does not have all the data necessary to produce the report, to provide the commission with data requested by the commission, as specified. The bill would amend the MHSA by authorizing a county to use MHSA funds to comply with these requirements. By requiring counties to submit annual reports, reports or provide specified data, this bill would impose a state-mandated local program.

The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement.

This bill would provide that, if the Commission on State Mandates determines that the bill contains costs mandated by the state, reimbursement for those costs shall be made pursuant to the statutory provisions noted above.

Existing law, the Mental Health Services Act, an initiative measure enacted by the voters as Proposition 63 at the November 2, 2004, statewide general election, requires the State Department of Health Care Services to establish a program designed to prevent mental illnesses from becoming severe and disabling.

This bill would make technical, nonsubstantive changes to that provision.

SENATE COMMITTEE ON APPROPRIATIONS

Senator Ricardo Lara, Chair

2017 - 2018 Regular Session

SB 1101 (Pan) - Mental health

This bill meets the criteria for referral to the Suspense File.

Bill Summary:

Senate Bill 1101 bill requires the Mental Health Services Oversight and Accountability Commission (MHSOAC) to establish statewide objectives (of which, no more than five as a core set) and metrics, as specified, for the prevention, early intervention, and treatment of mental illness. In addition, SB 1101 requires the MHSOAC to collect data and monitor the established metrics, and to work with specified stakeholders to monitor counties’ progress toward meeting the statewide objectives, as specified. The bill also requires counties, effective January 1, 2021, to report to the MHSOAC and the Legislature, as specified.

Fiscal Impact:

The MHSOAC estimates personnel and contract costs at approximately $1.75 million in the first year of implementation, specifically:

• To establish a strategy to collect, analyze, and monitor the established metrics. 2.0 RPS II’s ($230,616), 2.0 Systems Software Specialist 3 Technician ($278,736), and 1 AGPA ($95,568) for a total of $604,920 (new on-going resources)
• To develop outcome metrics and information tools, including new metrics: $900,000 (new, one-time) and $200,000 (new, on-going)
• One-time, start-up costs associated with legislative reporting requirements (consultation on how to report, information gathering, developing reporting strategy, analyze and update information): $250,000 (new, one time)

The MHSOAC reports the following implementation costs, which are planned to be absorbed:

• To establish statewide objective and corresponding metrics, as well as public engagement and meeting facilitation: Approximately $438,411 (current MHSA funds and resources)
• To establish a strategy to collect, analyze, and monitor established metrics: $535,336
• To establish a strategy for technical assistance, support, and evaluation to support the successful implementation of the objectives, metrics, data collection, reporting strategy: $217,385

Background:

1. Existing law establishes the MHSOAC to oversee the implementation of the Mental Health Services Act (MHSA), enacted by voters in 2004 as Proposition 63, to provide funds to counties to expand services, develop innovative programs, and integrate service plans for mentally ill children, adults, and seniors through a one percent income tax on personal income above $1 million.

Each county mental health program (counties) must prepare and submit a three-year program and expenditure plan, and annual updates, as specified, to the MHSOAC and Department of Health Care Services (DHCS) within 30 days after adoption by the county board of supervisors. In the three-year plans, counties must include a list of all programs for which MHSA funding is being requested and that identifies how the funds will be spent and which populations will be served. Counties also must submit their plans for approval to the MHSOAC before they can spend Innovation funds from the MHSA. The MHSA provides funding for programs the following components:

• Community Services and Supports (CSS): Provides direct mental health services to the severely and seriously mentally ill, such as mental health treatment, cost of health care treatment, and housing supports. Regulations require counties to direct the majority of its CSS funds to Full-Service Partnerships (FSPs). FSPs are county-coordinated plans, in collaboration with the client and the family, to provide the full spectrum of community services. These services consist of mental health services and supports, such as peer support and crisis intervention services; and non-mental health services and supports, such as food, clothing, housing, and the cost of medical treatment;
• Prevention and Early Intervention (PEI): Provides services to mental health clients in order to help prevent mental illness from becoming severe and disabling;
• Innovation: Provides services and approaches that are creative in an effort to address mental health clients’ persistent issues, such as improving services for underserved or unserved populations within the community;
• Capital facilities and technological needs: Creates additional county infrastructure, such as additional clinics and facilities and/or development of a technological infrastructure for the mental health system, such as electronic health records for mental health services; and,
• Workforce education and training: Provides training for existing county mental health employees, outreach and recruitment to increase employment in the mental health system, and financial incentives to recruit or retain employees within the public mental health system. 

In February 2018, the California State Auditor issued Report 2017-117, “The State Could Better Ensure the Effective Use of Mental Health Services Act Funding,” and noted that for FY 2015-16, LMHAs had accumulated $2.5 billion in unspent funds, of which $231 million should have been returned to the state to be redistributed among the LMHAs. For the same fiscal year, LMHAs cumulatively held reserves of $535 million in MHSA funds of which the CSA estimated between $157 million and $274 million were excessive and should have been returned to the state. Only one of 59 local mental health agencies submitted its annual report by the regulatory deadline.

The CSA report identified opportunities for DHCS to improve enforcement of regulatory deadlines. The CSA recommended that the MHSOAC finalize its internal processes by July 2018 in order to track LMHAs’ funding, services, and outcomes as it intends. The MHSOAC responded to that recommendation by saying it anticipates delays in receiving required reports from LMHAs.

Proposed Law:

The bill requires the MHSOAC:

• On or before January 1, 2020, to establish statewide objectives (a core set of ideally no more than five) for the prevention, early intervention, and treatment of mental illness, among others provisions.
• To establish corresponding metrics for each objective, and permits the establishment of metrics for each component. Requires the metrics to allow the public to meaningfully understand whether progress is being made against the established objectives.
• To establish a strategy to collect, analyze, and monitor the established metrics, using existing data, and propose new data collection and reporting strategies, if necessary.
• No less than once every five years, to review the established objectives, components, metrics, and strategies, as specified.
• To work with appropriate stakeholder, subject matter experts, counties, providers, state officials, and others the MHSOAC deems necessary in implementing the requirements of this bill.

In addition, the bill requires the counties, beginning January 1, 2021, to annually submit a report to the MHSOAC and to the Legislature, by the end of each fiscal year, that documents progress toward the statewide objectives using the metrics established pursuant to 2) above. The bill also authorizes a county’s use of MHSA funds to comply with these requirements.

Related Legislation:

The Legislature will consider a number of bills pertaining to the MHSOAC and the Mental Health Services Act, including:

• AB 2287 (Kiley) requires the MHSOAC to develop a local government transparency and accountability strategy for local mental health programs and state government. The bill would require the Department of Health Care Services adopt, by January 30, 2020, and update regulations regarding demographic reporting, related to the transparency and accountability strategy. The bill is pending in Assembly Appropriations Committee.
• SB 1004 (Wiener) requires the MHSOAC to establish priorities for the use of MHSA PEI funds, as specified, and to develop a statewide strategy for monitoring the implementation of PEI programs, as specified. Requires, commencing with fiscal year 2020-2021, funding for PEI programs to be distributed only after the MHSOAC approves the PEI plans, as specified. SB 1004 is being considered in Senate Appropriations Committee.
• SB 192 (Beall) requires counties, or counties acting jointly, seeking funding from the MHSA reversion fund, to demonstrate to the MHSOAC that funding will be used to create, or expand, existing capacity for services and supports that address unmet community needs. SB 192 is pending in the Assembly Health Committee.
• SB 688 (Moorlach) requires each county to prepare its Annual Mental Health Services Act Revenue and Expenditure Report in accordance with generally accepted accounting principles and to electronically submit the report in a machine-readable format to specified entities. SB 688 is pending in the Assembly Health committee.
• SB 1113 (Monning) permits the MHSOAC to establish a framework and voluntary standard for mental health in the workplace, as specified, and to provide guidance to California’s employer community to support the mental health and wellness of employees. SB 1113 is pending in Assembly Health committee.
• AB 2843 (Gloria) adds cities, special districts, school districts, or other public entities to the list of entities eligible to receive MHSA funds subject to reversion for the provision of mental health services consistent with the intent of the MHSA. AB 2843 is pending in the Assembly Appropriations Committee.

Staff Comments:

The Commission notes additional resources are necessary to establish the metrics and implement the requirements in SB 1101, projecting that it will take one to two years to establish the statewide objectives and corresponding metrics and a strategy to collect, analyze and monitor the established metrics. However, the MHSOAC notes the fiscal is preliminary, as additional resources may be needed once the metrics are adopted and finalized.

The MHSOAC notes its need to amend the Prevention and Early Intervention and possibly, the Innovation regulations, and its intention to coordinate with the Department of Health Care Services to amend the Community Services and Support regulations. The MHSOAC has one Chief Counsel and no support staff, and anticipates additional resources may be required to address further regulatory changes.

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SENATE COMMITTEE ON HEALTH

Senator Ed Hernandez, O.D., Chair

BILL NO: SB 1101

SUBJECT: Mental health

SUMMARY:

Requires the Mental Health Services Oversight and Accountability Commission (MHSOAC) to establish statewide objectives and metrics, as specified, to bring focus on the state’s mental health system and to assist the public in understanding whether progress is being made toward meeting the goals of the Mental Health Services Act, as specified. Requires the MHSOAC to collect data and monitor the established metrics, and to work with specified stakeholders to monitor counties’ progress toward meeting the statewide objectives, as specified. Requires counties to report to the MHSOAC and the Legislature, as specified.

Existing law:

1. Establishes the MHSOAC to oversee the implementation of the Mental Health Services Act (MHSA), enacted by voters in 2004 as Proposition 63, to provide funds to counties to expand services, develop innovative programs, and integrate service plans for mentally ill children, adults, and seniors through a 1% income tax on personal income above $1 million. [WIC §5845]
2. Permits the MHSOAC to perform various functions in carrying out its duties and responsibilities, such as:
3. Meeting at least once quarterly in locations convenient and open to the public;
4. Establishing technical advisory committees, such as a committee of consumers and family members;
5. Obtaining data and information from state or local entities that receive MHSA funds, as specified, to allow the MHSOAC to utilize in its oversight, review, training and technical assistance, accountability, and evaluation capacity, as specified;
6. Assisting in providing technical assistance to accomplish the purposes of the MHSA; and,
7. Working in collaboration with the Department of Health Care Services (DHCS), the California Behavioral Health Planning Council, and the California Mental Health Directors Association, as specified, to design a joint plan for a coordinated evaluation of client outcomes in the community-based mental health system, as specified. [WIC §5845]
8. Requires each county mental health program (counties) to prepare and submit a three-year program and expenditure plan, and annual updates, as specified, to the MHSOAC and DHCS within 30 days after adoption by the county board of supervisors. [WIC §5847]

This bill:

1. Requires, on or before January 1, 2020, the MHSOAC to establish statewide objectives for the prevention, early intervention, and treatment of mental illness; the promotion of mental health and well-being; and innovation as a strategy for transformational change. Requires the MHSOAC to establish a core set of objectives, as specified, that serve to bring focus to California’s mental health system, as specified.
2. Requires the MHSOAC to establish corresponding metrics for each objective, and permits the establishment of metrics for each component. Requires the metrics to allow the public to meaningfully understand whether progress is being made against the established objectives.
3. Requires the MHSOAC to establish a strategy to collect, analyze, and monitor the established metrics, using existing data, and proposing new data collection and reporting strategies, if necessary. Requires the MHSOAC to establish a strategy for technical assistance, support, and evaluation to support the successful implementation of the objectives, metrics, data collection, and reporting strategy. Requires the MHSOAC to periodically, but not less than once every five years, review the established objectives, components, metrics, and strategies, as specified.
4. Requires the MHSOAC to review the outcome and performance monitoring, data collection, and reporting requirements, and other oversight and accountability efforts in existence on January 1, 2019, to allow the MHSOAC to streamline those requirements to reduce cost, improve timeliness of relevant data, enhance the utility of reporting for decision-making, and support focus on the statewide objectives established by this bill. Permits the MHSOAC to obtain relevant data and information from other state entities to assist with monitoring of counties’ progress toward the statewide objectives.
5. Requires the MHSOAC to work with appropriate stakeholder, subject matter experts, counties, providers, state officials, and others the MHSOAC deems necessary in implementing the requirements of this bill.
6. Requires counties, beginning January 1, 2021, to annually submit a report to the MHSOAC and to the Legislature, by the end of each fiscal year, that documents progress toward the statewide objectives using the metrics established pursuant to 2) above. Requires the report to document mental health funding allocations from Medi-Cal and the MHSA in relation to the statewide objectives. Requires counties to provide data requested by the MHSOAC, if a county does not have necessary data to produce the report, to assist with the monitoring of the county’s progress toward the statewide objectives. Permits counties to use MHSA funds to comply with these requirements.
7. Prohibits the provisions in this bill from being construed to require counties to allocate mental health funding based on the statewide objectives. States Legislative intent that the statewide objectives work in concert with locally and regionally established goals to improve mental health outcomes statewide.
8. Declares that the requirements in this bill further the intent of the MHSA.

FISCAL EFFECT:

This bill has not been analyzed by a fiscal committee.

COMMENTS:

1. Author’s statement. According to the author, the goal of SB 1101 is to bring a cohesive leadership strategy to California’s mental health system spanning all counties and funding streams across the state. With approximately four million residents with mental health needs, and significant efforts focused on prevention and early intervention, our mental health system delivers an expansive array of services across its 59 local mental health agencies (LMHAs) and derives funding from Medicaid, Medi-Cal, and, most significantly, the MHSA. However, a recent report by the California State Auditor (CSA), “The State Could Better Ensure the Effective Use of Mental Health Services Act Funding,” found significant disparities between counties in the spending and use of MHSA funds. The CSA found that LMHAs had accumulated $231 million in unspent funds in FY 2015-16 and noted that lack of guidance from DHCS contributed significantly to the inability of LMHAs to maximize their potential. The CSA specifically called for increased guidance from the state and the need for the MHSOAC to develop statewide outcome metrics. Statewide leadership is needed to leverage our significant mental health resources into tangible change at the community level.
2. MHSA. The MHSA requires each county to prepare and submit a three-year plan to DHCS that must be updated each year and approved by DHCS after review and comment by the MHSOAC. In the three-year plans, counties are required to include a list of all programs for which MHSA funding is being requested and that identifies how the funds will be spent and which populations will be served. Counties also must submit their plans for approval to the MHSOAC before they can spend Innovation funds from the MHSA. The MHSA provides funding for programs the following components:
3. Community Services and Supports (CSS): Provides direct mental health services to the severely and seriously mentally ill, such as mental health treatment, cost of health care treatment, and housing supports. Regulations require counties to direct the majority of its CSS funds to Full-Service Partnerships (FSPs). FSPs are county-coordinated plans, in collaboration with the client and the family, to provide the full spectrum of community services. These services consist of mental health services and supports, such as peer support and crisis intervention services; and non-mental health services and supports, such as food, clothing, housing, and the cost of medical treatment;
4. Prevention and Early Intervention (PEI): Provides services to mental health clients in order to help prevent mental illness from becoming severe and disabling;
5. Innovation: Provides services and approaches that are creative in an effort to address mental health clients’ persistent issues, such as improving services for underserved or unserved populations within the community;
6. Capital facilities and technological needs: Creates additional county infrastructure, such as additional clinics and facilities and/or development of a technological infrastructure for the mental health system, such as electronic health records for mental health services; and,
7. Workforce education and training: Provides training for existing county mental health employees, outreach and recruitment to increase employment in the mental health system, and financial incentives to recruit or retain employees within the public mental health system. 
8. CSA report. In February 2018, the CSA issued Report 2017-117, “The State Could Better Ensure the Effective Use of Mental Health Services Act Funding,” and noted that a general lack of oversight from the state, particularly DHCS, resulted in LMHAs amassing unspent MHSA funds. For FY 2015-16, LMHAs had accumulated $2.5 billion in unspent funds of which $231 million should have been returned to the state to be redistributed among the LMHAs. For the same fiscal year, LMHAs cumulatively held reserves of $535 million in MHSA funds of which the CSA estimated between $157 million and $274 million were excessive and should have been returned to the state. The CSA attributed this to DHCS not having developed a process for recovering the unspent funds, known as reversion, or developed a prudent reserve formula. The CSA stated that a lack of enforcement from DHCS, such as withholding funds, does not incentivize LMHAs to submit required annual revenue and expenditure reports, which would assist DHCS in tracking unspent funds. The CSA noted that in the same fiscal year, only one of the 59 LMHAs submitted the annual report by the regulatory deadline.

The CSA also noted that the MHSOAC is taking steps to implement its responsibility to evaluate the effectiveness of MHSA PEI and Innovation projects. In August 2017, the MHSOAC launched an online MHSA fiscal transparency tool that uses an interactive map to display the LMHAs’ annual MHSA revenues, expenditures, and year-end balances of unspent funds. The CSA notes, however, that the effectiveness of this tool is contingent upon LMHAs submitting their annual revenue and expenditure reports on time, and DHCS has not enforced regulatory deadlines, and instead has regularly extended the timeframes for when LMHAs could submit the reports. The CSA recommended that the MHSOAC finalize its internal processes by July 2018 in order to track LMHAs’ funding, services, and outcomes as it intends. The MHSOAC responded to that recommendation by saying it anticipates delays in receiving required reports from LMHAs.

The CSA report also highlights the requirement in the MHSA that the MHSOAC review and approve LMHAs’ uses of Innovation funds before they can spend those funds. Of the $231 million in FY 2015-16 that should have been reverted to the state, 63% ($146 million) of that amount was Innovation funds. LMHAs told the CSA that several factors have led to difficulty getting Innovation projects approved, including the lack of clarity on the types of projects MHSOAC commissioners consider innovative. The MHSOAC formed a subcommittee in response to develop a flowchart for LMHAs and a template for them to present their projects, and also held a statewide meeting for LMHAs to share their innovative projects. The CSA report stated that from December 2015 through August 2017 the MHSOAC approved 83% of Innovation projects within three months of receipt. The MHSOAC stated that often the approval process is delayed because LMHAs submit and then withdraw their plans based on the readiness for review. The CSA stated that the MHSOAC’s efforts to provide technical assistance and improve dialogue with LMHAs should help reduce any delays in the approval process.

1. Related legislation. SB 192 (Beall) requires counties, or counties acting jointly, seeking funding from the MHSA reversion fund, to demonstrate to the MHSOAC that funding will be used to create, or expand, existing capacity for services and supports that address unmet community needs. SB 192 is pending in the Assembly Health Committee.

SB 688 (Moorlach) requires each county to prepare its Annual Mental Health Services Act Revenue and Expenditure Report in accordance with generally accepted accounting principles and to electronically submit the report in a machine-readable format to specified entities. SB 688 is pending in the Assembly.

SB 1004 (Wiener) requires the MHSOAC to establish priorities for the use of MHSA PEI funds, as specified, and to develop a statewide strategy for monitoring the implementation of PEI programs, as specified. Requires, commencing with fiscal year 2020-2021, funding for PEI programs to be distributed only after the MHSOAC approves the PEI plans, as specified. SB 1004 passed out of this Committee by a vote of 9-0 on April 11, 2018.

SB 1113 (Monning) permits the MHSOAC to establish a framework and voluntary standard for mental health in the workplace, as specified, and to provide guidance to California’s employer community to support the mental health and wellness of employees. SB 1113 passed out of this Committee by a vote of 9-0 on April 4, 2018.

AB 2843 (Gloria) adds cities, special districts, school districts, or other public entities to the list of entities eligible to receive MHSA funds subject to reversion for the provision of mental health services consistent with the intent of the MHSA. AB 2843 is pending in the Assembly Appropriations Committee.

1. Prior legislation. AB 462 (Thurmond, Chapter 403, Statutes of 2017) permits the Director of the Employment Development Department to share information with the MHSOAC related to quarterly wage data to assist the MHSOAC in fulfilling its duties under the MHSA, as specified.

AB 850 (Chau of 2017) would have added a Governor-appointed member to the MHSOAC who has knowledge and experience in reducing mental health disparities, especially for racial and ethnic communities. AB 850 was vetoed by the Governor who stated that the MHSOAC as currently constituted is up to the task entrusted to it.

AB 860 (Cooley of 2017) would have permitted the MHSOAC to conduct a fact-finding tour of a facility or location that is not open to the public, as specified. AB 860 was vetoed by the Governor who stated that individual MHSOAC members can and do visit locked mental health facilities, jails, psychiatric hospitals, and schools to observe mental health care services firsthand, and that AB 860 could disrupt treatment programs or compromise the privacy of those receiving services.

AB 974 (Quirk-Silva, Chapter 411, Statutes of 2017) requires counties to report spending on mental health services for veterans from MHSA funds.

AB 1134 (Gloria, Chapter 412, Statutes of 2017) permits the MHSOAC to establish a fellowship program, in accordance with specified principles, for the purpose of providing an experiential learning opportunity for a mental health consumer and a mental health professional.

1. Support. The American Foundation for Suicide Prevention (AFSP) states early intervention and treatment of Californians suffering with mental health issues may vary widely from county to county, but their goals should be the same: a healthy community. AFSP argues that with 58 counties working independently to meet the needs of their communities, there needs to be statewide common objectives to bring focus on the mental health of all Californians. AFSP states that this bill would establish a strategic, statewide focus for how counties treat those with mental illness and bring about measures to record and evaluate how counties are utilizing MHSA funds and other sources.

SUPPORT AND OPPOSITION:

Support: American Foundation for Suicide Prevention

Oppose: None received

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