Steinberg Institute

RAND: CA’s Mental Health Services Act Benefits Tens of Thousands in L.A. County

Posted on Tuesday, March 13, 2018

Contact: Deborah Anderluh, 916-553-4167

LOS ANGELES – California’s Mental Health Services Act has benefitted tens of thousands of Los Angeles County residents, funding services that fostered significant improvements in mental health and wellbeing, as well as measurable gains in housing, employment and living conditions, according to findings of a new RAND Corporation report.

The 53-page report, commissioned by Los Angeles County, is the first extensive, independent analysis of the county-level impacts of the Mental Health Services Act, or Proposition 63, a millionaire’s tax approved by California voters in 2004. The tax generates more than $2 billion annually for mental health care in California, funding programs that span from early intervention and prevention to full-service, wraparound care for people whose lives have been disabled by a serious brain illness.

The RAND report focuses exclusively on Los Angeles County, home to more than 10 million residents and the nation’s largest public mental health system. Given California’s decentralized approach to mental health services – in which all 58 counties operate with relative autonomy – the analysis does not purport to reflect every county’s experience. But given L.A.’s size and its share of MHSA revenue, the findings serve as a major statement on the meaningful impacts of Proposition 63.

RAND analyzed outcomes for three core programs that accounted for just under half of MHSA spending in Los Angeles County in the five years covered by the analysis. Among the key findings:

  • From 2012-2016, more than 130,000 young people, ages birth to 21, received MHSA-funded services from Los Angeles County that focused on prevention and early intervention. The majority of these services were provided in low-income neighborhoods. Many of the children served had been exposed to trauma, violence and family dysfunction, among the childhood experiences known to pose major risk factors for later onset of mental and physical illness and substance use disorders.
  • The prevention efforts were overwhelmingly successful: Among the young people who had not shown significant symptoms of mental illness before receiving services, nearly 90 percent remained below the threshold for clinically significant symptoms in the year following treatment. Among those with clinically significant symptoms at the start of treatment, half fell below that threshold after receiving services.
  • From 2012-2016, Los Angeles County served more than 24,000 children, young people and adults living with serious mental illness via full-service partnerships, programs that provide “whatever-it-takes” services to reorient clients whose lives are perilously off-track because of their brain illness.
  • More than 90 percent of the adults targeted for full-service partnership services were unemployed and about half were homeless, making them a particularly challenging population to serve. The analysis found rates of homelessness and inpatient hospital stays fell dramatically for those who stayed in the program, while rates of employment and connection with a primary care doctor markedly improved.
  • Most of the children and young adults enrolled in these full-service partnerships suffered from depressive disorder, schizophrenia or other psychotic conditions. Their overall rates of homelessness and inpatient hospital stays were significantly reduced over the course of treatment.

Los Angeles County mental health officials commissioned the RAND evaluation to get a better sense of who they were reaching with MHSA spending and the quality of the services provided. The researchers concluded the county is reaching a highly vulnerable and diverse population, and that overall the people engaged in those programs experience significant improvements in their mental health and life circumstances.

“This is exactly the kind of analysis needed to help us hone and grow our services across populations,” said Dr. Jonathan E. Sherin, Director of the Los Angeles County Department of Mental Health. “But for us, it’s only the beginning of how we can use data and outcomes to help point the way forward. We know these services are effective and are laser focused on expanding programs that work by taking them to the streets, neighborhoods, libraries, schools and parks where we can more robustly reach people in need.”

Steinberg Institute founder Darrell Steinberg authored the Mental Health Services Act while serving in the State Assembly in 2004 as part of his broader mission to strengthen mental health services in California. Steinberg, now Mayor of Sacramento, said the report sheds welcome light on the impacts of a unique and precious funding stream.

“There have been several audits criticizing the MHSA, but we finally have some great news to share today,” Steinberg said. “This report demonstrates to the public what we have known for many years:  tens of thousands of people are getting desperately needed help. The MHSA is affecting thousands of lives.”

Taken as a whole, the report underscores the remarkable benefits of early intervention efforts, in terms of both the human toll and as a cost-effective public investment. At the time the Mental Health Services Act was drafted, California was struggling with an underfunded mental health care system and a critical shortage of community-based care for people disabled by mental illness. By design, the act requires counties to spend 80 percent of their MHSA funds on community services for people experiencing mental health crisis. Just 20 percent of the funds are targeted for prevention and early intervention.

Even so, the RAND analysis reflects an outsized impact from PEI spending. The authors note that Los Angeles County did not offer PEI services before passage of the Mental Health Services Act. It now coordinates a broad array of prevention and early intervention strategies, ranging from services for young people experiencing the early stages of psychotic illness to programs meant to “catch” youth before they experience declines in mental and emotional health in response to sustained physical or emotional trauma. The report highlights the impacts of five evidence-based programs Los Angeles County funds that fall into this latter form of prevention.

The services described are offered through school-based clinics in some communities, and in others, at mental health centers. Most of the children referred for services live in low-income neighborhoods with high levels of crime, gang activity and violence. Many were referred for care after showing unusual signs of aggression, anger, emotional distress or social isolation.

“One of the moving stories I see in these findings is how critical it is that we pour resources into preventive, front-end care for brain illness – exactly as we would for a physical illness,” said Maggie Merritt, Executive Director of the Steinberg Institute, a Sacramento-based nonprofit dedicated to advancing the cause of brain health in California.

“Los Angeles is working hard to provide transformative care at both ends of the spectrum, but getting treatment to people whose illness has progressed to the point they are living on the streets is heartbreakingly complicated. We have to continue to bend that curve, intervening early and reaching people before they suffer and fall. L.A.’s experience shows how effective that can be.”

The other core services measured in the RAND analysis involved programs known as full-service partnerships that offer intensive services for people whose illness is far more progressed and whose living conditions are often dangerously unstable. The adults targeted in full-service partnerships typically suffer from a serious mental illness — schizophrenia, depression or bipolar disorder – that has gone untreated and progressed to the point of severe dysfunction. Many are living homeless, making them harder to find and treat with regularity. Many have a history of repeat incarcerations and emergency hospitalizations. They typically have lost connection with family and friends. Often, their illness is so advanced they don’t understand they need help.

FSP programs are designed to address the full range of needs for this population, and by their very nature are individualized and time-consuming. It can take months to build the relationship necessary to get a mentally ill person off the streets, and months more to find housing and establish a stable treatment environment. And as is true of many serious diseases, the longer a brain illness goes untreated, the more damaging it becomes and the more difficult it can be to reverse the course of the disease.

The RAND findings indicate the county is making strong headway despite the challenges. Over the five-year period, Los Angeles County was able to newly enroll 12,000 adults in FSP programs. Nearly two-thirds of the clients enrolled during the five-year span had successfully completed their program or were still actively engaged in services at the end of 2016.

For adults who stuck with the program, progress was meaningful: The rate of homelessness plummeted from 46 percent to 20 percent. The portion of adult clients with inpatient stays for mental health or substance use disorders fell from 22 percent before enrollment to 16 percent in the year after. The portion of clients employed rose, from 5 percent to 8 percent during that time frame.

Children and transition-aged youth enrolled in full-service partnerships – comprising another 12,000 clients – also saw measurable gains from MHSA-funded services. Nearly three-quarters of children enrolled in FSP services completed the program during the five-year span or remained actively engaged, as did more than half the transition-aged youth. As with the adults, those who completed their program were less likely to be homeless or hospitalized for a mental health or substance use issue in the year following treatment.

The RAND analysis marks a milestone in the trajectory of the Mental Health Services Act. Earlier studies coordinated by the institute found evidence the MHSA had brought life-changing services to tens of thousands of families, but the RAND report is the first extensive, independent analysis of county-level outcomes.

“We know we have more to do to ensure California is spending its mental health dollars strategically and effectively across all 58 counties,” added Merritt. “But it’s also gratifying to see how far we’ve come.”

Access the full report here.



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