Rose King’s 12/2/12 Memo on Problems with MHSA


December 2, 2012                                Rose King

RE: Mental Health Services Act Audit, California State Auditor, Bureau of State Audits

The MHSA is straightforward in its purpose, but made complicated in its application by policies that violate the purpose and intent of the law.

  1. The practical implementation of the Mental Health Services Act has little in common with the language of the law—with Prop 63 campaign promises—or with the Legislative Analyst’s Ballot Analysis.  The 2004 MHSA has been violated by implementers at the state, legislative, and county levels. I am one of several co-authors, a principal witness and opponent of official deception. From the start, and by every measure, California has violated its contract with voters.


Several years into MHSA funding, an LA Times article quoted the county mental health director as saying: “We have people coming in and we have to say: ‘I’m sorry, you’re not sick enough. But when you get really sick, come back and see us.”  I was startled to read the very same words that I heard 40 years earlier when my husband Joe King and I sought help for his mental illness.  Joe did get really sick and died by suicide two weeks after he was turned away. I have worked in politics all of my professional life while advocating for a second and now third generation of family members in both private and public mental health systems. I know how much and how little has changed.

The Factual Purpose: MHSA allocates 70% of revenue to upgrade “existing county mental health systems of care” and strive to meet the standards of a proven service model, exhaustively explained in Welfare And Institutions codes. “Systems of Care” have been funded, evaluated, improved, and praised as pilot programs since 1989, but never able to serve more than 5% of consumers until Prop 63 generated the money to raise standards in existing systems. MHSA emphasized Integration of all services, collaboration, and defined the primary target population. The blueprints and foundation for success were already in place. MHSA dedicates at least 20% of revenue for new, integrated Prevention/Early Intervention programs, as a vital component of these expanded Systems of Care.  New “PEI” programs serve people with mental illnesses at critical points to prevent further disability and severity of illnesses, and to maximize recovery options for people with untreated or poorly treated mental illnesses—many already lost in the system and some never likely to connect with the system unless these prevention programs are up and running. PEI programs also improve linkages with educators, primary care providers, and others likely to need knowledge of community resources.

The Corruption of purpose:  Dept of Mental Health rejected expansion of mental health “Systems of Care” with known standards, principals, and treatment options in specified WAI code sections—and instead invented a plan called “Community Supports and Services” (CSS), used the 75% of revenue for a two-tier system of new programs for new clients, and excluded existing clients and programs.  DMH and the Oversight and Accountability Commission reversed the clear intent of Prevention/Early Intervention provisions, prohibiting services to people with mental illnesses, funding programs unrelated to mental illnesses, and creating a “slush fund” for local officials. The state and counties still work to misinform public officials and stakeholders, who are not prepared to evaluate system expansion, prevention, or innovation; the community is not engaged in decisions. The state refused to implement MHSA Requirements for Integrated County Plans, ensuring a divide between MHSA and core systems of care.
The legislated purpose and intent of the law was corrupted and a rationale invented post-passage.
Bureaucrats, Politicians, Special Interests operate independent of law. My personal perspective—$Billions intended to upgrade California’s crisis-driven, public mental health system are controlled by a self-appointed Board of Directors, operating MHSA as their private foundation. The Directors—not the people’s law—set priorities and determine intent.

THE STATE MUST REGAIN CONTROL to begin serving the desperate people deprived of any hope of recovery, and to keep faith with the people of California. It is not the people who have betrayed us—it is the same brand of governors, legislators, and lobbyists who refused to deliver services for the last 40 years—and who now have now hijacked treatment money.

Q. Why Can State Operate Independent of the People’s Law?

Q. Why Can State Ignore Widespread Opposition to Distortion of Law?   

A. Because there is no accountability at any level, no parameters for programs or spending.  

How does implementation differ from the law and the campaign promises?

  1. No Accountability at Any Level – No Authority to Stop Misuse of Funds and Distortion of Law.  Overall, 100% of MHSA county revenue intended for historically underfunded mental health systems is accessible to local officials, who divert considerable amounts for social programs unrelated to mental illnesses, without state objection. Funding decisions may be influenced by political interests because there are no universal guidelines—no ground-rules supporting the language and legal intent of law. It’s a Free-For-All attracting entrepreneurs and private consultants competing for the money intended to improve consumer services.  There are no incentives to maximize use of treatment dollars for best practices. There is no definition, much less a plan, for success.


No Foundation or Management Structure to Govern Policies and Spending.
The Dept. of Mental Health never developed a public, documented MHSA implementation plan, and defied the 2008 Dept. of Finance audit calling for a known plan. State leaders operated MHSA by a seat-of-the-pants, ad-hoc, Wild West code.  The Dept. of Health Care Services follows the same chaotic pattern, leaving compliance and oversight to the discretion of county mental health directors.

No Data To Track and Report Accountability and Compliance with Law.
No state entity tracks quality, access, capacity to meet consumer needs in each county mental health system. The state has no reported or planned oversight that measures annual county system status, service improvements, or progress toward standards of codified Systems of Care. There are no indications from DHCS that the state is working to fulfill requirement for “Integrated” mental health systems, developed with public participation.   The state fails to integrate services at great human and fiscal peril.

No State Entity Can Determine Whether any County Complies with Requirements to serve specific target populations with MHSA money. The state funds MHSA programs in every county without baseline data—and without diagnostic tracking. DHCS, OAC, and CMHDA lack data on each county to determine merits or actual demand for funded services provided by any given program No county is obliged to track or report on consumer needs and capacity to meet those needs.

Counties are free to determine their own rules for MHSA spending and programs, leaving county compliance to the interpretations of local mental health directors and controllers, who continue to support the TWO-TIER SYSTEM AND UNLAWFUL PEI PROGRAMS. No state entity knows if MHSA programs actually fill a vital consumer need or system gap in any given county. The state has not defined any terms for county compliance with actual law or even the corrupted interpretation of law.

KEY CHALLENGE FOR AUDITORS—absence of any accountability measures that demonstrate system progress from one year to the next.


  1. NO MHSA FUNDING for Expansion of Existing Systems of Care OR Creation of New Prevention/Early Intervention Programs. NO STATE OBJECTION to Violating Voter Intent, and Reinventing Purpose and Intent of Law After Passage.  The state has abdicated its obligation to ensure compliance with spending of state tax revenue. The governor and the legislature demonstrated a willingness to shift money and responsibility to counties with no strings attached.

TWOTIER SYSTEM. DMH ignored its own Implementation Studies of 2007, all three of which reported that MHSA revenue is creating a “dual system,” which is the chief complaint of stakeholders. The California Mental Health Directors Association objected to “Two-Tier” System, explaining in 2009 that DMH policies could lead to a system of “haves and have-not’s” in treatment of mental illnesses. The Association requested a moratorium on new regulations in 2010 because DMH policies strayed so far from original intent of MHSA. NAMI CA, the California affiliate of national family and consumer advocates, submitted three surveys to the DMH and OAC, illustrating constituent complaints about MHSA implementation in 2007, 2008, and 2010—reporting in November 2008 that MHSA is funding a parallel mental health system, which excludes current clients.  MHSA funds are not devoted to enhancing and expanding Systems of Care.  NAMI CA members believe this results in discrimination and was not the intent of Prop 63.   DMH and OAC Acknowledge Need to Avoid Two-Tier System and recognized NAMI CA reports of 2007 and 2008 in a Power Point briefing.  for personnel and appointees. SEE Slide 22 FollowtheMoneyFinal. In correspondence with OAC Chair Lynford Gayle in September-October 2008, Mr Gayle expressed his concern and OAC plan for action, stating: “These issues have already been raised during joint workgroup meetings designed to produce the Integrated Plan Guidelines. MHSOAC Staff and Commissioners will continue to advocate strongly for a final solution to the two-tiered mental health system crisis and for a solid MHSA Implementation Plan to be developed.”  
PREVENTION/EARLY INTERVENTION DISTORTION. MHSOAC Political Appointees Reverse the Purpose of PEI—to prohibit services to very people intended to benefit.  The purpose of prevention/early intervention provisions is to help people with mental illnesses to prevent lifelong disabilities and reduce the duration of untreated mental illness.  OAC Guidelines are contrary to the language of the law and clear voter intent. The OAC Commissioners prohibited services and programs for people diagnosed with mental illnesses—the very people the law intended to benefit! DMH translated the OAC document into Regulations and county requirements.

The rationale for Reinterpretation is invented post-passage—and there is no record of such plans in Prevention Committee planning and reports. There are no lawful arguments to support taking this money for unrelated purposes.  “Healthy Communities” and improvement of the “larger social context,” cited by the MHSOAC, may be admirable goals. But this is not a practical “Vision” for our communities, but a “Pipe Dream,” absent leadership of county and city officials, schools, churches, businesses, etc.
The OAC presumed the authority to amend the law and improve the  “larger social context”  because the MHSA is open to exploitation; as the Dept of Finance, 2008 OSAE audit pointed out, there is no overall, documented public plan, so policies and priorities are not limited by specific, long-term goals for integrated, functional Systems of Care. NOW, for similar reasons, the MHSOAC presumes to issue county guidelines for spending and program plans.
OAC PREVENTION COMMITTEE AND MHSOAC Meeting Minutes track the process, and reveal that certain stages of development of the guidelines are not a subject of stakeholder and public input. The prohibition against serving people with a diagnosed mental illness was not in earlier versions of the guidelines, and the unlawful interpretation invented in later years. (SEE PEI Guidelines FY 2007-08 and 2008-09.)  The lawful purpose is exactly as voters intended, based upon many campaign messages seeking their support.
Yes on Prop 63 Campaign Message from Proponent Senator Darrell Steinberg Disputes the MHSOAC Interpretation.  September 27, 2004
Prop. 63 will also provide integrated services to people with mental illness in order to help them prevent their illnesses from becoming severe and disabling. We know that we can prevent mental illness from becoming severe and disabling in most cases.We know that prevention reduces the likelihood of suicides and suicide attempts. And we know that many people who want prevention services can’t access thembecause there is inadequate funding to make them available to everyone who wants them. Prop. 63 is our opportunity to change that–to make those services accessible and available to people who want them.”

  1. Will Legal Action Be Necessary to Compel the State to Follow Provisions of Law? Can Legal Action Compel Compliance with Interpretations of Law in Campaign Messages that Solicit “YES” votes on Prop 63?   The campaign for “YES” votes on Prop 63 appealed to voters by promising expansion of existing, proven programs, already described in California state codes, and creation of integrated prevention programs. The campaign for “YES” on Prop 63 assured voters that program expansion and spending will be consistent with voters’ wishes. Voters relied upon campaign messages, MHSA “Purpose and Intent” language, and the ballot statement of the Legislative Analyst.

Here are Messages of the YES ON PROP 63 CAMPAIGN WEBSITE:
“Who will ensure that the money is spent properly?
The measure creates a new Citizens Oversight and Accountability Commission to annually review each county’s expenditure plan and ensure that all expenditures are in accord with the voters’ wishes.

In addition, the initiative only authorizes services in accordance with the Children’s and Adults’ Systems of Care.  These systems require each county’s expenditures for each person to be approved by the State Department of Mental Health.  All expenditures are audited by state and local agencies and all service providers are subject to local oversight and state licensing.”
Here are Messages from Senator Darrell Steinberg, YES ON PROP 63 CAMPAIGN : April 23, 2004 Programs will follow established model and standards already in the law—guidelines are already established.
The initiative is drafted so that it will fit right into existing Welfare and Institutions Code provisions regarding mental health… The Welfare and Institutions Code establishes a system of community mental health services, including an adults’ and a children’s system of care, for mental health services.”
The purpose and intent of INTEGRATED PREVENTION/EARLY INTERVENTION PROGRAMS explained in Yes on Prop 63 Campaign Message from Proponent Senator Darrell Steinberg.  September 27, 2004 “Prop. 63 is designed to provide integrated services not only to people with severe mental illness who have become homeless, but also to adults and children who have a severe mental illness and who are at risk of becoming homeless. Prop. 63 will also provide integrated services to people with mental illness in order to help them prevent their illnesses from becoming severe and disabling.

“We know that we can prevent mental illness from becoming severe and disabling in most cases.We know that prevention reduces the likelihood of suicides and suicide attempts. And we know that many people who want prevention services can’t access thembecause there is inadequate funding to make them available to everyone who wants them. Prop. 63 is our opportunity to change that–to make those services accessible and available to people who want them.”
DMH Plan excluded the underserved people that Senator Steinberg said Yes on Prop 63 would serve.  Senator Darrell Steinberg, October 14, 2004. 
“The system of mental health services will be vastly improved when counties have the funding to serve more people in need, and serve them in the client-centered manner, with integrated services, that meet the standard of best practices….the need is now an urgent one. With each cut, more people who qualify for services and are there asking for help have to be turned away.” California has no uniform, mandatory standard of best practices for public mental health systems.

  1. MHSA Was Reinterpreted after Passage by Voters.  DMH Director Mayberg Explains How MHSA Was Modified.  I challenged the two-tier process developed by the DMH plan in correspondence sent to all MHSOAC Commissioners, DMH leaders, Boards of Directors of stakeholder organizations, and in public presentation to OAC.  I asked: Why are counties directed to find new consumers for MHSA programs, when they need look no further than their clinic waiting rooms for people deprived of essential services?”

DMH Director Stephen Mayberg answered my question; he did not challenge my contention about the results of reinterpreting the law, but explained why different choices were made: “Informed by the MHSA and stakeholder input, we determined that the best initial course of action was to use at least half of the money to fully serve some individuals through Full Service Partnerships and to prioritize those services to those most in need.” 

Minutes from 2004-05 stakeholder meetings and Dept of Finance, OSAE AUDIT did not support Mayberg claims regarding stakeholder participation. The May 2008 Audit questioned faulty stakeholder process.
“Although DMH indicated that all stakeholders were in agreement with the deviations, the overarching plan and vision was not sufficiently documented...goals are not known to all, and counties and stakeholders are limited from effectively planning or creating programs within their communities.”

The complete audit, recommending 19 corrective actions was delivered by the Dept of Finance to administration officials and legislative leaders in June 2008, and covered in Rose King Whistleblower Complaint of November 2009. There is no record of public stakeholder discussions to support Mayberg’s claim of stakeholder influence over deviation from MHSA provisions—no public discussion of who is “most in need” of “FSP” services—which absorb far more than half and closer to 100% of CSS funds.

  • Standards spelled out in Systems of Care, Welfare And Institutions codes, for children, adults, and older adults are not the basis of stakeholder proceedings, as the state never briefed counties and volunteer participants.
  • Stakeholders were misled to believe that MHSA revenue could not be used to improve existing programs, but must fund new programs.
  • When DMH management rejected Systems of Care, counties were instructed to follow a plan of unknown origin, which set implementation on an unguided course.
  • Systems of Care code sections and all the related standards, principles, and proven practices are not referenced in DMH Requirements or Regulations for counties and stakeholders.
  • With no uniform guidelines or ethics for stakeholder participation, every county reinvented  the wheel. “CSS” and its three categories of funding were an invention of DMH, NOT a provision of the law.  The anticipated, cost-efficient, client-effective plan was replaced by chaos and contradiction.
  • Rejecting Systems of Care, DMH started with a blank slate planning process, far more costly and time-consuming, and absent known standards. The three unnecessary categories of service for CSS plans created by DMH, including “Full Service Partnerships,” compounded complexities of the law, and created a massive public and private bureaucracy for new programs and newly recruited clients, with expenditures for outreach to find new clients while inappropriately treated consumers continued to receive substandard services.

The MHSA policy of New Programs for New Clients is a major source of waste, with pricey management for every new, often over-staffed, and sometimes underutilized program. The process generated endless committees, work-groups, meetings, conferences, “visioning,” and a boon to a private and public industry of consultants, event planners, trainers, and production of endless studies, glossy brochures, meeting and conference materials.
MHSA Is Reinterpreted Again when DMH leaders say they cannot produce Requirements for Integration of MHSA components and existing systems required by the law—a vital, core value of the MHSA and model programs in Systems of Care. Incredibly, DMH announced it would not implement this essential provision of MHSA.  (MHSA Section 10, 5847. Integrated Plans for Prevention, Innovation and System of Care Services and 5848 (c). ) MHSA amendments in AB 1467, 2012-13 budget trailer bill now leave Integrated Programs and Revenue Streams unresolved.
Counties continue to manage MHSA as a categorical program, with county MHSA budgets reviewed and approved separate from the core system. MHSA and Realignment programs and funding remain separate, contrary to explicit intent, and indifferent to numerous stakeholder demands for integration of programs and revenue streams.


September 05, 2011|By Anna Gorman, Los Angeles Times
A man hearing voices walked into the emergency room of downtown’s California Hospital Medical Center on a recent night and said he wanted to hurt somebody. Doctors gave him medication, put him in a hospital bed and called the Los Angeles County Mental Health Department.
A mental health worker placed the patient — who had a history of schizophrenia — on a psychiatric hold. But despite multiple attempts to find somewhere to treat him, he spent 3 1/2 days in the emergency room…”We are inundated with these patients,” said Marc Futernick, California Hospital’s director of emergency services. “The design of the system is that everyone gets taken care of in a timely fashion. The system is broken…”
Local watchdogs point to years of unwise spending in Santa Clara County
BY KAREN DE SA, Bay Area News Group, The Daily News, Wednesday, June 1, 2011, Page A5

California’s Mental Health Services Act of 2004 envisioned the creation of desperately needed programs for the mentally ill, flooding counties with new money from a tax on millionaires.

But in Santa Clara County, according to current and former leaders of the local mental health oversight board, the money — including some of this fiscal year’s $68 million in funding — has been spent in misguided ways. They say consultants take precedence over clients, planning meetings over direct care, and all too often appearance over substance — such as a current $180,000 plan to create nine, eight-to-12-minute videos “for the purpose of mental health promotion” in ethnic communities….”


Mental Health Spending Creating Haves and Have-nots
Mental Health Services Act spending not fulfilling all expectations

From The Mercury News by Karen de Sá, June 26, 2011
“Seven years after voters approved a new tax to fund services for people with mental illness, California has slashed so much money from mental health departments that it now leads the nation in such cuts.
Counties have laid off psychiatrists, reduced hospital bed space and shut down mental health clinics.
And the $7.4 billion generated by the mental health tax
Much of it has gone to a cottage industry of consultants earning up to $200 an hour, as well as a host of new programs that in many cases are only loosely linked to prevention, treatment and recovery.
The Bay Area News Group examined spending to date under the Mental Health Services Act of 2004, after reporting in May concerns expressed by the chairman and former chairwoman of a Santa Clara County watchdog group. They charged that local spending under the act has resulted in frivolous programs and enriched private contractors at the expense of people desperately in need of care.
The newspaper group found problems are evident statewide, despite years of warnings from a high-level whistle-blower and other mental health authorities….”
“The state of California clearly did not comply with the law and they did not keep and honor the contract with the voters,” said Rose King, co-author of the Mental Health Services Act, which appeared on the November 2004 ballot as Proposition 63. “It’s a corruption of purpose, and it’s a boondoggle for consultants and entrepreneurs at the expense of core services.”
Two-tiered mental health system
Sacramento News and Review
By Reporter Amy Yannello               9/15/11

“• According to the most recently available data from the state, only 4.6 percent of the 443,655 Medi-Cal clients in the county mental health system statewide, received services through wraparound services.
 • additionally, by the state’s own admission, no data system supported by the counties or maintained by DMH currently tracks all the clients or services that are tied to the act. As a result, outcomes are impossible to track with accuracy.
• In 2010-11, the state is allocating more than $133.5 million for prevention and early intervention services—some of the programs claiming only loose ties to serious mental illness. For example, as some counties are not funding services for “severe” mental illness, but for “stress reduction” through “yoga, line dancing, drumming, and soul Chi (soulful movement)” and “equine-facilitated psychotherapy, and drumming for Indian youth reading below grade level or exhibiting problems.”
California Mental Health Dollars Bypassing Mentally Ill
Hannah Drier, AP
SACRAMENTO – “As state mental health services have crumbled under budget cuts, tens of millions of dollars raised through a tax designed to help the mentally ill have gone to “wellness” programs like horseback riding for teens and yoga classes for city workers. And that’s by design.
Voters approved Proposition 63, the so-called “millionaire’s tax,” in 2004 to make up for decades of mental health cuts. The ballot summary said it would “expand services and develop innovative programs” for the mentally ill and the text of the measure stipulated 20 percent of the funds would go to programs “effective in preventing mental illnesses from becoming severe” and “reducing the duration of untreated severe mental illnesses…”

Mental Breakdown: Series of Stanislaus County Reports in Modesto Bee

Photography Gallery: Faces of Mental Illness
Lauren M. Whaley, CHCF Center for Health Reporting | May 20, 2012
Everyone pictured here has a mental illness. They live in this community. A daughter. An uncle. A sister. A friend. A neighbor. A co-worker.
And everyone pictured here receives or gives help at the Stanislaus affiliate of the National Alliance on Mental Illness (NAMI), which serves as a kind of community center for those who have nowhere else to go, or who want to help mental illness find a more normal place in Modesto. Some attend group therapy sessions there. Others – more than 50 – volunteer to take their peers to the movies or to tell their personal stories to groups and each other in the hopes of bringing mental illness out of the shadows.
Read More
Mental health care breaking down in Stanislaus
Jocelyn Wiener, CHCF Center for Health Reporting | May 20, 2012
They appear here after every other door has been shut on them. Some are haunted by multiple voices or schizophrenia, others paralyzed by anxiety and depression.
Inside this simply furnished room at the Stanislaus chapter office of the National Alliance on Mental Illness, sick people with nowhere else to turn, and their worried family members, struggle to help one another navigate a shrinking mental health safety net.
In recent years, a faltering local economy has combined with ongoing state and county budget cuts to severely reduce Stanislaus County’s ability to treat adults with mental illnesses – a trend reflected around California.

Normalizing Mental Illness: One Mom’s Hope (Multimedia)
Lauren M. Whaley, CHCF Center for Health Reporting | May 20, 2012
In recent years, a faltering local economy has combined with ongoing state and county budget cuts to severely reduce Stanislaus County’s ability to treat adults with mental illnesses – a trend reflected around California. In four years, the county department of Behavioral Health and Recovery Services, which oversees mental health services, has lost more than 200 positions – some 37 percent of its staff. In 2003-4, the department was able to serve nearly 13,000 county residents. Today, that number has dropped closer to 9,000, while the need almost certainly has grown.

Hospital ERs see dramatic increase in mentally ill patients
Ken Carlson, Modesto Bee | May 20, 2012
Hospital emergency rooms in Stanislaus County are feeling the impacts from the statewide shortage of psychiatric beds and cuts to outpatient services.
In the past five years, Emanuel Medical Center in Turlock has seen a dramatic increase in ER patients with a psychotic diagnosis, from 276 in 2007 to 681 in 2009. There were 591 visits last year.
Emanuel officials said it’s happening all over California.

Mental health by the numbers
Center Staff, Modesto Bee | May 20, 2012
Mental illness: Who to call for help in Stanislaus County
Center Staff, Modesto Bee | May 20, 2012
Mental Breakdown: Project Partners
Center Staff, Modesto Bee | May 20, 2012
Mentally ill languish in jails due to cuts, lack of beds
Jocelyn Wiener, CHCF Center for Health Reporting | May 21, 2012
The latest chapter of Kim Green’s recurring nightmare began last fall.
In October, her 24-year-old daughter – who suffers from severe bipolar disorder and a mood disorder related to schizophrenia – was booked into the county jail after being arrested on a probation violation. In December a judge declared the young woman incompetent to face charges and ordered her to Napa State Hospital to get well.
But with no beds available at Napa, Green said, her daughter instead spent five months in the jail.
This story was originally published in The Modesto Bee.
Is Prop. 63 missing mental health goals?
Drew Joseph
Published 9:28 p.m., Sunday, December 2, 2012

Proposition 63, which voters approved in 2004, was touted as a way to address serious mental illnesses in California, but in the years since, critics – including some of the original supporters – have argued that it has gone off the rails in its implementation.
They have questioned how the $7 billion the measure has generated – from a 1 percent tax on income above $1 million – has been spent, accusing state and county officials of squandering millions on public relations campaigns, consultants and programs loosely tied to mental illness.
Funds generated by Prop. 63, also known as the Mental Health Services Act, are meant to expand services for the mentally ill, develop new programs and stop mental illness from becoming disabling.
Critics say the programs were not what voters were promised when they approved Prop. 63.
“It’s a complete distortion of the law,” said Rose King, who helped write the measure and is now a vocal critic.

Mental Health Services Act Not As Advertised
The history and evidence of Two-Tier System is further documented in a Whistleblower Complaint filed by Rose King on November 2, 2009 with the California State Auditor