Friday, August 6, 2010 | Mental health care in Orange County and elsewhere is undergoing a paradigm shift that is in large part due to massive budget deficits and California’s propensity for ballot-box budgeting.

The county is transitioning away from a traditional care model in which the focal point is the one-on-one relationship between patient and clinician to one where a patient’s care is parceled out to a variety of separate programs and services.

The reason for this has more to do with where the money flows than anything else.

Countywide mental health services budgets have been slashed by $43 million since 2007, according to Orange County Health Care Agency officials. Meanwhile, money is flowing in from Proposition 63, or the Mental Health Services Act, an initiative approved by voters in 2004 that taxes millionaires another 1 percent and directs the money to mental health programs.

The catch with the new money is that it cannot be used to fund mental health programs that already exist.

So Orange County ends up with the closure of at least one traditional outpatient clinic in Costa Mesa, as well as a reduction in clinician services at the county’s other outpatient clinics in Anaheim, Fullerton, Westminster, Mission Viejo and Santa Ana.

But Proposition 63 money is paying for new programs like job replacement services, prevention and early intervention programs, community education plans, mobile crisis management teams and even the construction of new mental health facilities. About 160 employees have already shifted to working under the new programs, according to Health Care Agency officials.

“The old services are gone. Those people being funded to be clinicians in their old roles just aren’t there anymore,” said Mark Refowitz, deputy director of behavioral health services, a department of the Health Care Agency.

Refowitz says the agency’s new mental health care model will provide solutions that connect people with their communities and get them back to work and living normal lives. Those solutions, he says, will hopefully keep people from needing traditional outpatient care.

Others, however, aren’t ready to buy into the new focus.

Dr. Jay Slosar, who served as president of the Orange County Psychological Association in 2004, is worried about cuts to outpatient clinics. He said the personal relationship between the clinician and the patient is the “nitty gritty” of mental health treatment and simply can’t be replaced. Diagnosis, follow-up sessions and “continuity of care” form the foundation of any mental health treatment plan, Slosar said.

“The ongoing [clinician-patient] relationship is what’s important,” Slosar said. “Any time you cut corners like that you’re going to see an impact on quality.”

County Supervisor John Moorlach says the funding arrangement is a result of the “law of unintended consequences” that can be triggered when budgets are put together at the ballot box. Moorlach says it’s just one example of revenue streams that local government has no control over.

“We’re cutting core services for what I would call in the budget ‘luxury items,’” Moorlach said. “It’s a frustration.”

Refowtiz said core services are still being provided and the neediest are not falling through the cracks.

The clinician services are only being scaled back for adult patients without a medical necessity as defined by state law, Refowitz said, and that makes up about 50 percent of the patients served. To qualify, walk-in patients at the clinic are assessed by an on-site professional. If they’re deemed not sick enough, they’re referred to “other places,” he said.

“Even though we’ve had significant reductions, we’ve tried to keep ourselves to the folks with the most severe and persistent mental illness,” Refowitz said.

Slosar, however, argues that the cuts on mental health services can have dramatic consequences on society. People with mental health problems often end up in jail, and without access to outpatient clinics, jails could start filling up with indigents.

“When you cut back on these core services, they’re going to end up in jail — and they don’t deserve to be there,” Slosar said.

Refowitz defended Proposition 63, saying it has provided an array of “outstanding” programs that never could have existed before.

Many of the Proposition 63-funded programs are designed to cater to the underserved — which include a complex mix of needs, like being on the verge of homelessness or a member of an ethnic group that holds stigmas toward the mentally ill.

Other programs, like the mobile response teams, assist police and firefighters on calls involving the mentally ill. There are also community treatment programs that focus on group, rather than individual, therapy.

Refowitz points to early intervention programs as being one solution to the cutbacks to core services. Although these programs are still being put together, if mental health problems can be addressed early on, then there would be no need for more intensive services in the future.

Refowitz declined to say, if it were up to him, how he would arrange the funding priorities or if they seem as backwards to him as they do to Moorlach. But, he said, he’s just grateful that Proposition 63 is there.

“The better question would be … what would it look like if we didn’t have the Mental Health Services Act?” Refowitz asked.

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