San Francisco Chronicle - (Sunday)
Will CARE Court, conservatorship actually help California in 2024?
Homelessness in California hit a record high in 2023. Meanwhile, San Francisco logged more fatal drug overdoses than it did in 2020, formerly its deadliest year. One might think numbers like these would inspire state and local leaders to get on the same page in addressing the crises.
Instead, they closed out the year by bickering over who is more to blame.
Just like in November 2022 — when Gov. Gavin Newsom abruptly announced that he was withholding $1 billion in state homelessness funding because of local governments’ “unacceptable” plans to reduce homelessness by just 2% — the governor closed 2023 by threatening to use a similar tactic to force counties to more rapidly implement SB43, the biggest reform to California’s conservatorship law in decades. Significantly more people can be involuntarily compelled into behavioral health treatment under the law, including those with substance use disorder. But only a few counties, including San Francisco, are choosing to implement the law on Jan. 1, with many deferring adoption until the Jan. 1, 2026 deadline.
Counties “have to do their job with a deeper sense of urgency,” Newsom said at a recent news conference. “People are dying on their watch.”
Counties cried foul. Local behavioral health systems, already overstretched and understaffed, are being asked to implement complex new laws with “yet-to-be-identified resources, physical (capacity) and workforce capacity,” said Michelle Doty Cabrera, executive director of the County Behavioral Health Directors Association of California.
Newsom is right to demand increased transparency and accountability from counties. But he also needs to be realistic about what counties can accomplish under current conditions.
As our editorial board has documented over the past year, California has a severe shortage of mental health beds at all levels of acuity, leaving tens of thousands of severely mentally
ill people with nowhere to go but the streets, jail or prison. The lack of capacity has created persistent bottlenecks in California’s behavioral health system, leaving some people with improved conditions trapped in locked facilities even as others with acute needs languish in lower-level settings or on the street.
That’s a main reason why most counties are choosing to delay implementation of SB43: The system can’t handle a significant jump in conservatorships. Hospital emergency rooms are already overflowing with patients waiting for inpatient psychiatric beds and state hospital placements. Nor are there any locked facilities in California that specifically treat people with substance use disorder, according to local officials.
Mark Ghaly, secretary of California’s Health and Human Services Agency, recently acknowledged that in some cases, “we’re going to have to define and identify places where these individuals can go.”
But, he argued, “We can always find reasons to slow-walk just about anything.”
The state’s impatience is understandable. In San Francisco, for example, nearly 8% of the city’s supportive housing units intended for people exiting homelessness were vacant in late December, even as shelters turned people away due to lack of capacity. Existing resources
clearly aren’t being used wisely: After years of debate, city leaders are preparing to open a tiny home village in the Mission in 2024, but the site will only be open for a year despite each cabin costing a whopping $113,000. Meanwhile, progress on addressing homelessness, mental illness and substance abuse in other areas is so slow that frustrated parties are turning to lawsuits. Sacramento County District Attorney Thien Ho recently sued his own city over proliferating encampments, while a group representing downtown businesses sued the city and county of Los Angeles to force them to commit to providing more housing and behavioral health beds.
But California also runs the risk of encouraging counties to incentivize speed at the expense of safety. People with severe behavioral health issues need appropriate care — they shouldn’t be thrown into the first housing unit that becomes available simply because politicians are trying to clean up the streets ahead of the 2024 elections.
That doesn’t mean sitting back and allowing people to deteriorate on the streets. But placing severely ill people in inappropriate housing is also unacceptable and can lead to serious consequences.
In May, a San Francisco man named Fook Poy Lai was released from a state mental hospital after serving a prison sentence for violent assault connected to his severe mental illness. Lai ended up in a single-roomoccupancy hotel without onsite services in the middle of an open-air drug market. Exactly one week later, he was accused of violently stabbing a Chinatown bakery worker in the neck.
Such violent cases may be outliers; research shows that mentally ill people are more likely to be victims of crime than perpetrators of it. But they nevertheless underscore the importance of placing individuals with severe needs in facilities capable of meeting their needs.
“We have so many people in our hotels who should not be there,” Randy Shaw, executive director of the Tenderloin Housing Clinic, San Francisco’s biggest nonprofit SRO operator, told the editorial board.
Such situations seem likely to continue under CARE Court, Newsom’s signature program to direct people with schizophrenia and other psychotic disorders into housing and treatment. Although participants are eligible for housing funded by a wide variety of sources, they’re explicitly prioritized only for “behavioral health bridge housing” funding — a pot of state money that covers short- to mid-term placements in settings such as tiny homes, hotels and motels, assisted living facilities and rental subsidies. Supportive services aren’t necessarily located onsite, though participation is voluntary either way.
Robert Okin, former chief of psychiatry at Zuckerberg San Francisco General Hospital, told the editorial board that he’s worked with mentally ill homeless patients whose condition deteriorated after they were placed in housing due to the lack of onsite services and support.
And CARE Court isn’t even the biggest worry: San Francisco had received just 18 petitions as of Dec. 26, according to Judge Michael Begert, who oversees the local CARE Court. The most urgent question is where the thousands eligible for California’s new conservatorship law will be housed.
Newsom is sponsoring a March 2024 ballot measure that would require counties to spend a significant portion of their mental health funds on housing people with the most complex needs and offering them intensive wraparound services. It would also authorize nearly $6.4 billion in bonds to build behavioral health facilities and housing and invest in a highly trained workforce.
But, even if voters approve the measure, it likely will take years for many of these facilities to materialize.
Meanwhile, other monies the Newsom administration is pouring into behavioral health are mostly temporary.
“How do we sustain programs that have been started using one-time or time-limited funds?” Hillary Kunins, San Francisco’s behavioral health director, asked the editorial board. The bridge housing money prioritized for CARE Court participants, for example, runs out in June 2027.
Despite the obvious limitations of CARE Court and expanded conservatorship, the state clearly feels that it’s done its part to address the multipronged crisis on our streets.
“We’ve met the expectations that have been set by local leaders,” Newsom recently said. “We’ve exceeded them in so many ways. … We just need local partners that are as enthusiastic, passionate and being willing to be accountable as the state.”
Local officials view it differently.
“Cities and counties have been really left in many, many ways on their own by the federal and state government,” Kunins said.
With San Francisco and California staring down massive budget deficits in 2024, policymakers’ handling of this period will be pivotal. With collaboration, we have a chance at meaningfully making a dent in unacceptable street conditions. But if officials sacrifice this long-term goal for cheap political fixes and deflections, we can expect more of the same on our streets next year.