Mental health care plan debated
S.F. politicians are at odds over cost of free treatment
A proposed ballot measure to offer free mental health care to all San Franciscans would be a gargantuan undertaking meant to hit at the heart of the city’s homelessness crisis. But with no guaranteed source of funding, public health officials say it could also force the city to more than double its budget for those services.
No one disputes the need for more care: The Department of Public Health spends about $400 million a year on behavioral health services, from crisis-care units to substance-abuse-treatment programs. Still, an untold number of people find themselves without timely and affordable access to the care they need. That contributes to the huge number of people living on the streets — estimated at more than 8,000 — with about a third suffering from mental illness.
But backers of the proposal and its critics, including Mayor London Breed, question whether the city can afford such an extraordinary and expensive attempt at a solution.
Supervisors Matt Haney and Hillary Ronen recently proposed the November ballot measure — dubbed “Mental Health SF” — to provide quick, free and 24/7 access to psychiatrists and pharmacists to any city resident with or without insurance. With six confirmed votes on the Board of Supervisors, the measure is expected to qualify for the ballot by the end of July. If approved by voters, the city would be required to build a drop-in center, and create a new Office of Coordinated Care with case managers to follow patients through a treatment plan. Supporters say the proposal is not only ambitious, but necessary to fix holes in the city’s mental health care system.
“The current system is disconnected, it’s disjointed and there isn’t a treatment plan that follows someone through the system,” Haney said Monday at a meeting of The Chronicle’s editorial board. “The result is that people enter the system in some way ... and then fall through the cracks.”
Haney and Ronen acknowledge a dedicated funding source is not guaranteed, but said one option is a second ballot measure they plan to propose Tuesday: a new gross receipts tax on companies that pay their chief executives more than 100 times the median compensation paid to employees. Money from that would be directed to Mental Health SF. That proposal — for the March ballot — would also need board approval and, if it qualified for the ballot, a two-thirds vote to pass.
That means Mental Health SF could pass in November without a dedicated source of funding. But the supervisors said Monday they could get money from the state and are working on other options, partly with help from Assemblyman Phil Ting.
The city’s Budget and Legislative Analyst Office released a report Monday estimating that the program would cost at least $70 million a year, but said the actual cost would depend on client need.
The city would also need to spend a one-time cost of $32 million to establish the components of the program, the report said.
But the Public Health Department, which would run the program, says those figures don’t come close to what they believe it would cost to give everyone free mental health care based on the proposal.
The Public Health Department estimates that, as written, Mental Health SF would cost the city between $244 million and $1.1 billion annually, depending on how many San Franciscans use it. Those estimates don’t include the capital costs of creating the drop-in center to hold all the services, which the department said could cost another $278 million. The department calculated the numbers based on its existing programs and staffing.
Ronen and Haney pushed back against those numbers Monday, saying the public health department grossly overestimated how many employees would be needed.
“These numbers are laughable. These figures are seven times the accounting from our official budget and legislative analyst,” Ronen said. “I hate to say it, but once again the Department of Public Health is giving numbers and data that make no sense."
Breed assailed the proposal through a spokesman Monday, and said she has serious concerns about its feasibility. She criticized the supervisors for drafting the proposal apparently without consulting the Public Health Department, and said the ballot measure needs much more work before it goes before San Francisco voters.
“No one would ever draft a ballot measure overhauling our city’s fire response without talking to the Fire Department,” said her spokesman, Jeff Cretan. “These initial numbers show that this program needs a lot of work, and we shouldn’t be rushing to the ballot so quickly.”
Breed’s spokesman also questioned how likely private insurance companies would be to reimburse the city if it provided insured patients with mental health services or medication.
As politicians argue about the wisdom of Mental Health SF, Breanna Blueford, 37, said she loves the idea. Blueford lives in an assisted living facility in the Bayview but said she doesn’t get the mental health treatment she needs there.
She has been waiting for years to get a psychiatrist and therapist, she said. Diagnosed with depression and anxiety, Blueford visited Dore Urgent Care Clinic — which functions as an emergency room for those in a psychiatric emergency — Sunday night when she found herself in need of immediate mental health care.
Dore, which contracts with the city, was the only place Blueford knew of to get the help she needed. She hopes to get placed into a two-week treatment program at Dore and then its three-month program. But she’s gone through this cycle twice before, only to be left at the end of it with no consistent care, she said.
“I’ve been trying to get outpatient services for almost four years now — a therapist or a psychiatrist — and can’t get it,” Blueford said Monday. “I’ve never had a case manager. Never got a call back.”
“The system is broken,” she added. “It’s really, really broken.”
People like Blueford who cycle in and out of the system are exactly the reason an overhaul of the system is needed, Ronen said. “The solution is not little fixes here and there. This is a failed system that needs to be rethought and redesigned.”
The city has about 2,000 treatment beds across more than 300 different programs. Since becoming mayor in July, Breed has added about 100 beds and plans to add another 100 in next year’s budget. The Board of Supervisors also recently passed a small expansion to the city’s conservatorship program, which allows it to involuntarily hold people in severe need of mental health care.
Supervisor Rafael Mandelman — whose main priority in office is mental health reform — has nevertheless opposed the ballot measure as it’s currently written. He said the 11-member board unanimously agrees that the city needs more mental health services, but that there is no need to bind the city to such a costly and rushed endeavor through the ballot.
“I believe in big bold ideas and in pushing envelopes,” he said. “But they are marrying audacious goals with a particular policy response that doesn’t necessarily achieve those goals, and that are going to cost a ton of money and actually divert us from more immediate solutions.”
Jacob Kaminker, former president of the San Francisco Psychological Association, said it is important to provide immediate services to anyone who needs it — regardless if they have insurance or not.
“Even people who have insurance often cannot find services. I have to turn away people every day because there is just not enough coverage and providers out there,” he said. “Do I think this will fix the problem entirely? Probably not. But any increase in services is moving in the right direction.”