As many mental health services in Orange County suffer the consequences of chronic underfunding – such as shortages of psychiatric beds and wait times for psychiatrists stretching into months – the county has built up about $220 million in unspent taxpayer money that California voters specifically earmarked for expanding mental health services.
The funds come from the Mental Health Services Act, a 1 percent tax on millionaires’ income that was approved by voters in 2004. It injects more a billion dollars each year into mental health programs overseen by county governments, including about $119 million in Orange County this fiscal year.
The law requires counties to set up a "prudent reserve,” which in Orange County's case is $71 million, that can only be used amid economic slowdowns. But, as of July, the county has built up another $149 million in unspent funds.
The law’s co-author says that’s definitely not what it was intended for.
“They have all that money, in contingency funds and unspent from last year, while…someone in crisis has to wait three months for an appointment,” said Rose King, a mental health advocate who served as chief of staff to former Lt. Gov. Leo McCarthy and co-wrote the measure.
The underspending has also brought criticism in the past from Orange County supervisors’ Chairman Todd Spitzer.
“I understand why we have reserves when it comes to the county of Orange…but when you have this money that’s specifically earmarked for mental health services in our community, I lose the rationale for a contingency,” Spitzer said during a 2013 supervisors’ meeting.
“In my opinion, every single dollar shouldn't be in a bank…it should be out on the street, helping people get services."
Yet, while much of the money sits in the bank, advocates and mental health professionals say many mental health needs are going unmet, including a shortage of psychiatric beds so acute there are no local beds available for young children until 2017.
A recent grand jury report determined the county should have about 1,500 psychiatric beds, based on the recommended ratio by the California Hospital Association. But the county has just 685, the jurors found.
A county-provided list, meanwhile, shows about 900 beds. And the shortage of children’s beds will be somewhat alleviated in 2017, when an 18-bed facility at Children's Hospital of Orange County is slated to open.
Another issue is a shortage of psychiatrists, who diagnose and help treat many mental health conditions before they escalate into more serious issues, including, in some cases, violence.
At a recent Orange County Board of Supervisors meeting, several child psychiatrists testified that their caseloads stretch into hundreds of clients, with long waiting times before the first appointment, and each appointment after that.
They attributed the long wait times to a shortage of available doctors due to the county paying below market salaries, amid hundreds of thousands of dollars in student loans that many psychiatrists have to pay off.
Current job listings for Orange County advertise front-line psychiatrist salaries from $157,000 to $180,000 per year. The range for San Bernardino County goes from $167,000 to $239,000 and Los Angeles County goes from $140,000 to $245,000. The bonus pay and benefit packages also vary from county to county.
In a letter that was read aloud, Dr. Angela Yu wrote that four psychiatrists have left the county-run Anaheim clinic she works at in the past eight months, but no replacements have been hired.
One of her patients, she said, is a homeless and mentally ill man who recounted pouring gasoline on himself in an effort to commit suicide. But with over 350 “severely mentally ill” patients assigned to her, Yu said she wasn’t scheduled to see him for another two months.
“I can’t tell you how many times I’ve watched a patient walk out of my door and I’ve thought to myself, ‘Please still be alive in two months,’” Yu wrote.
County administrators, meanwhile, say that while appointments at the most impacted clinics can take up to four weeks, appointments in many clinics are available the same week. The county is also setting up a 24-hour "open access clinic" where people can be seen by a psychiatrist the same day.
Regarding the psychiatrist shortage, administrators say it's a nationwide issue, and that they hope to hold on to psychiatrists longer, and fill the open positions, by offering to help pay for their student loans.
“Hopefully we can attract…and sustain the psychiatrists that we hire” through such efforts, said Jenny Qian, the county’s chief of operations for behavioral health.
As for the accumulation of unspent funds, Qian said many of the county’s mental programs are new, and can take years to properly plan and implement. So funds that are set aside for programs might not actually be used until a couple of years later.
Qian also attributed some of the unspent dollars to extra funding that comes in mid-year and is rolled over to the next year. And she underscored that using any of the $71 million “prudent reserve” is restricted by the state to certain economic conditions.
Additionally, she said the county plans to significantly draw down the unspent dollars over the coming years, including $8 million to $10 million for a community planning process next fiscal with the total figure slated to go down by tens of millions of dollars.
Orange County isn’t the only place that has accumulated large reserves of mental health dollars.
San Diego County built up a $172 million fund balance as of 2013, according to the San Diego Union Tribune, with Los Angeles, San Bernardino and Riverside counties also accumulating large amounts of mental health funding.
Other areas of unmet need were identified by the county grand jury in two reports earlier this year. Among the panel's findings the need for involuntary psychiatric emergency services “is not being met” in South County, and that sheriff’s deputies and police officers “receive insufficient training on how to evaluate and handle the mentally ill in the field.”
The county’s mental illness triage system is also “inadequate,” the grand jurors found, because police either don’t have a triage desk available to help them in the field or don’t have “psychiatric crisis mobile response teams” available.
The system also lacks “strategically located, stand-alone, drop-off psychiatric emergency stabilization facilities with medical treatment capability at convenient locations throughout the County,” jurors found.
Many of the underlying problems with the mental health funding rests with a lack of state oversight and later changes to the law that emphasize funding new services instead of expanding existing ones, said King, the law’s co-author, who also served as then-Attorney General Bill Lockyer’s top consultant regarding the mental health law’s oversight commission.
In the ballot title of the Mental Health Services Act, voters were told they were voting for a “mental health services expansion,” King pointed out. But after the measure passed, regulations were written to gear it towards funding new services, she added.
Meanwhile, oversight problems were outlined in a 2013 audit by the California state auditor, which found that the state has provided “little oversight” over counties’ implementation of the law.
“None of the entities charged with evaluating the effectiveness of [Mental Health Services Act] programs—[the California Department of] Mental Health, the Accountability Commission, or a third entity—have undertaken serious efforts to do so,” states a summary of the findings.
Counties also “rarely developed specific objectives to assess the effectiveness of the programs,” the audit found.
Despite the report, King said, oversight problems continue to be rampant.
“There’s no accountability, and the California state auditors declared this. And nothing changed.”