Mental Health Services Act (Proposition 63)

• Abstract
• Purpose of health policy or idea
• Characteristics of this policy
• Political and economic background
• Purpose and process analysis
• Expected outcome
• References

Abstract

Proposition 63 provides funds to the state and counties to expand and develop programs and services for the mentally ill, including prevention, early intervention and education. It also creates a commission to approve certain county mental health programs and expenditures and imposes a 1% tax on taxpayers? personal income above $1 million to provide dedicated funding for expansion of mental health programs. It prohibits the state from decreasing current funding levels for mental health services.

Purpose of health policy or idea

The main purpose of Proposition 63 is to expand mental health services for all Californians.  Studies have shown that mental health care programs reduce government expenditures associated with crime, law enforcement, incarceration, and other social problems associated with mental illness.

Main points

Main objectives

The main objectives of Proposition 63 are:

• Provide funds to counties to expand services and develop innovative programs and integrated service plans for mentally ill children, adults and seniors.

• Require the state to develop mental health service programs including prevention, early intervention, education and training programs.

• Create a commission to approve certain county mental health programs and expenditures.

• Impose an additional 1% tax on taxpayers' taxable personal income above $1 million to provide dedicated funding for expansion of mental health services and programs.

• Prohibit the state from decreasing funding levels for mental health services below current levels.

Type of incentives

Proposition 63 specifies that revenues generated from the personal income tax surcharge must be used exclusively to expand mental health care services. In addition, the state and counties would be prohibited from redirecting funds now used for mental health services to other purposes. The state would specifically be barred from reducing General Fund support, entitlements to services, and formula distributions of funds now dedicated for mental health services below the levels provided in 2003-04.  The purpose of these restrictions is to significantly increase the availability of state mental health programs and services.

Groups affected

Government (governor, state legislature and county governments), providers (mental health professionals), consumers/patients (underserved adults and children needing mental health services and wealthy taxpayers)

Innovationsgrad	traditionell		innovativ
Kontroversität	unumstritten		kontrovers
Strukturelle Wirkung	marginal		fundamental
Medienpräsenz	sehr gering		sehr hoch
Übertragbarkeit	sehr systemabhängig		systemneutral

Proposition 63 was a controversial ballot initiative because it experiments with a new funding mechanism for mental health programs, i.e. income taxes for the very wealthy.  Understanding why Proposition 63 passed and its effects on the delivery of mental health services will be important for policymakers nationwide, evaluators at the UC Berkeley Nicholas C. Petris Center say.  According to Richard Scheffler, "Proposition 63 has potentially important implications not only for California but for other states as well. Some have begun to debate whether this is good social policy; does it set the stage for other special-needs advocates to propose categorical taxes to support their programs and services, and does it relieve the legislature of responsibility for establishing priorities in policy and spending?"  Neal Adams, special projects director at the California Institute of Mental Health, says "Perhaps more important is whether new money can make a difference in the quality and effectiveness of public mental health systems. Other states would be wise to observe the implementation challenges and impacts of this bold experiment before rushing to the ballot box."

Political and economic background

In the state of California, there has been increased recognition of the need for greater availability of mental health care services. Proposition 63 was passed by 53.4 percent of the vote. It was strongly supported by mental health assiations across the state.  County Mental Health Services. Counties are the primary providers of mental health care in California communities for persons who lack private coverage for such care. Both children and adults are eligible to receive such assistance. Counties provide a range of psychiatric, counseling, hospitalization, and other treatment services to patients. In addition, some counties arrange other types of assistance such as housing, substance abuse treatment, and employment services to help their clients. A number of counties have established so-called "systems of care" to coordinate the provision of both medical and nonmedical services for persons with mental health problems.

County mental health services are paid for with a mix of state, local, and federal funds. As part of a prior transfer of mental health program responsibilities from the state to counties, some state revenues are automatically set aside for the support of county mental health programs and thus are not provided through the annual state budget act. Other state support for county mental health programs is provided through the annual state budget act and thus is subject to change by actions of the Legislature and Governor.

State Personal Income Tax System. California 's personal income tax was established in 1935 and is the state's single largest revenue source. It is expected to generate an estimated $39 billion in revenues for the support of state government in 2004-05. The tax is levied on both residents and nonresidents, with the latter paying taxes on income derived only from California sources. Tax rates range from 1 percent to 9.3 percent, depending on a taxpayer's income level.

The mentally ill were cared for in asylums or state hospitals until the late 1960s, when states began closing those hospitals in favor of community-based treatment. Thousands escaped often-grim institutions but experts say the community based programs have never been adequately funded. According to a recent report by Human Rights Watch, 1 in 6 prison inmates is mentally ill, making correctional institutions America's primary mental-health facilities. California has more mentally ill people in prison than in psychiatric hospitals. In 1999, the California state legislature enacted Assembly Bill 34, which has since been expanded to provide services to 4,500 mentally ill people across the state.   Proposition 63 further expands these services.

Purpose and process analysis

Current Process Stages

	Idee	Pilotprojekt	Strategiepapier	Gesetzgebung	Umsetzung	Evaluation	Veränderung/Richtungswechsel
Implemented in this survey?

Origins of health policy idea

Darrell Steinberg (D), California state Assemblyman, co-authored Proposition 63. Proposition 63 is based on earlier, successful mental health legislation (AB34) Steinberg introduced shortly after he took office in 1998.  AB34 initially provided $10 million to fund pilot projects for community services to the mentally ill. The bill was the direct progenitor of Proposition 63 and marked the first significant investment in mental health in decades.                          

One year after the pilot projects were funded in 1999, Steinberg said, "we found that the 1,000 people helped under AB34 were showing the beginnings of real success, with decreased hospitalizations and reduced homelessness." He points to impressive statistics from the AB34 projects: Participants had a 56 percent reduction in hospital stays, a 72 percent reduction in jail stays and a 65 percent increase in full-time jobs. The success of the pilot projects prompted Steinberg to push for more funding, and to take the matter directly to the voters during his final year in the Assembly, where he was termed-out in 2004. Thus, Proposition 63 was born.

Steinberg and Rusty Selix, the longtime executive director of the Mental Health Association of California, led the Proposition 63 campaign, organizing a coalition of supporters who included the mentally ill and their families - people who historically were excluded from mental health policy-making. The coalition raised $5 million to place Proposition 63 on the ballot and secure its passage.

Initiators of idea/main actors

• Regierung: The governor opposed Proposition 63, and state and county governments were neutral. None of these government actors greatly influenced Proposition 63, but they are important stakeholders in it.

• Leistungserbringer: Providers and provider associations strongly supported Proposition 63. They exerted a strong influence on its design and passage.

• Patienten, Verbraucher: The majority of California voters supported passage of Proposition 63. Most voter support came from urban areas, e.g. San Francisco and Los Angeles. Wealthy taxpayers neither supported nor opposed the initiative (median income was found to be uncorrelated with yes votes).

Approach of idea

The approach of the idea is described as:
renewed: Proposition 63 is a direct outgrowth of pilot mental health programs funded by AB34.

Innovation or pilot project

Stakeholder positions

Darrell Steinberg (D), California state Assemblyman, and Rusty Selix, the executive director of the Mental Health Association of California, led the Proposition 63 campaign.  They put together a broad coalition of children and senior organizations, elected officials, physicians, community mental health providers, concerned families and many others to support passage of Proposition 63.  The California Department of Mental Health is responsible for mediating conflicts among stakeholders involved in the implementation phase.

Actors and positions

Regierung
Governor	sehr unterstützend		stark dagegen
State legislature	sehr unterstützend		stark dagegen
County governments	sehr unterstützend		stark dagegen
Leistungserbringer
California Psychiatric Association	sehr unterstützend		stark dagegen
American Hospital Association	sehr unterstützend		stark dagegen
California Psychological Association	sehr unterstützend		stark dagegen
Patienten, Verbraucher
Urban residents	sehr unterstützend		stark dagegen
Non-urban residents	sehr unterstützend		stark dagegen
Tax limitation groups	sehr unterstützend		stark dagegen

Influences in policy making and legislation

Proposition 63 was passed in November, 2004 and is since being implemented in various stakeholder counties.  The proposal has not been altered or amended to date.

Actors and influence

Regierung
Governor	sehr groß		kein
State legislature	sehr groß		kein
County governments	sehr groß		kein
Leistungserbringer
California Psychiatric Association	sehr groß		kein
American Hospital Association	sehr groß		kein
California Psychological Association	sehr groß		kein
Patienten, Verbraucher
Urban residents	sehr groß		kein
Non-urban residents	sehr groß		kein
Tax limitation groups	sehr groß		kein

Positions and Influences at a glance

Monitoring and evaluation

The Nicholas C. Petris Center at Berkeley, which has received funding from the California HealthCare Foundation, will undertake a three-year study to monitor and report on the implementation of Proposition 63.

Review mechanisms

Abschlussevaluation (extern)

Dimensions of evaluation

Prozess, Ergebnis

Results of evaluation

Evaluation results will be reported in 2007 or 2008.

Expected outcome

Impact of this policy

Qualität	kaum Einfluss		starker Einfluss
Gerechtigkeit	System weniger gerecht		System gerechter
Kosteneffizienz	sehr gering		sehr hoch

Proposition 63 will increase the supply of mental health care services for disadvantaged adults and children in California.  The impact on the quality of these services is unknown, although results from pilot programs funded by AB34 suggest programs have positive effects for mentally ill populations. Proposition 63 program costs are expected to be offset by reductions in government expenditures for the homeless, prisons, and crime.

References

Sources of Information

· "Proposition 63: Mental Health Services Expansion, Funding. Tax on Personal Incomes above $1 Million": www.smartvoter.org/2004/11/02/ca/state/prop/63/ and www.lao.ca.gov/ballot/2004/63_11_2004.htm

· The Nicholas C. Petris Center for Health Care Markets and Consumer Welfare:http://www.petris.org/docs/millionaires_and_mental_health_press_release.htm

· Supporters of Proposition 63: www. Yeson63.org

· Opponents of Proposition 63: www.HealthyCalifornia.org

· MHSA Web page at the California Deaprtment of Mental Health: www.dmh.cahwnet.gov/MHSA/default.asp

Author/s and/or contributors to this survey

Anke Therese Schulz (UCSF) and Carol Medlin (Institute for Global Health, UC Berkeley and UCSF)

Empfohlene Zitierweise für diesen Online-Artikel:

Anke Therese Schulz (UCSF) and Carol Medlin (Institute for Global Health, UC Berkeley and UCSF). "Mental Health Services Act (Proposition 63)". Health Policy Monitor, April 6, 2006. Available at http://www.hpm.org/survey/us/d7/2