Progressive Democrats totally fucked up San Francisco and New York
City.
For years, Bill Gene Hobbs stalked, harassed, kissed and groped women on
the streets of San Francisco. Almost immediately recognizable because of
his 6-foot-4 frame, dead eyes and many tattoos including the word
E-V-I-L inked across his knuckles Hobbs once allegedly followed and
grabbed a 15-year-old, calling the young girl an angel and his
perfect mate.
On Thursday, a judge sentenced Hobbs to 2œ years in county jail and
three years in state prison after a San Francisco jury unanimously found
him guilty of battery, sexual battery and assault and felony false
imprisonment.
But even as survivors celebrated the ruling, questions remained as to
how Hobbs was allowed to terrorize women for so long.
After Hobbs was arrested for grabbing the 15-year-old, he was found
mentally incapable of defending himself. The court, however, wasnt able
to find a treatment bed for him. And so Hobbs was released from jail
after serving his maximum sentence, free to harass once more with no
treatment.
Many people in San Francisco no doubt see in Hobbs case the broader
failure of the city to address the behavioral health crisis on its
streets. Blame swirls in all directions. Some argue the citys liberal
permissiveness and scattershot approach to criminal justice have put the
rights of lawbreakers above the safety of the general public. Mayor
London Breed blames an overabundance of compassion, and insists its
time for a tougher approach to unruly and dangerous behavior in the
streets. Progressive supervisors, meanwhile, say a hyper-focus on
policing at the expense of data-driven behavioral health treatment is
the culprit.
Amid the local finger-pointing, however, few are meaningfully
questioning the role the state of California has played in allowing
these crises to grow and fester.
State government is no idle actor in San Franciscos issues. The
policies it dictates, the departments it runs and the budget priorities
it sets all carry local impacts that cities like San Francisco are in
many ways powerless to resolve on their own.
Perhaps nowhere is that more the case than in the realm of mental
health.
Its true, San Francisco has consistently failed to react with the
urgency required to meet its behavioral health crisis. We have dithered
on outreach and infrastructure. We have allowed NIMBYism and PR to
interfere with data-driven plans.
But the state bears culpability, too.
In his inability to access mental health treatment, Hobbs was no outlier
California has an extreme shortage of mental health beds. And it has
failed to adequately care for its hardest-to-serve population: people
with mental illness who also have a criminal record including those
with a history of violence.
This population disproportionately causes bottlenecks in Californias
mental health delivery system, impacting care for other vulnerable
residents. And governments consistent refusal to rise to the challenge
of meeting this demographics unique needs is a crucial driver of the
chaos on our streets. Its a problem San Francisco and many other of
Californias cities and counties cant solve alone. Only with serious
and sustained state intervention will we see meaningful improvement.
To come to this determination, the Editorial Board reviewed thousands of
pages of documents, studies and government reports, and conducted
interviews with nearly two dozen experts, including government
officials, policy wonks, hospital staff, social workers and mental
health activists with lived experience in Californias systems of care.
How we got here
Understanding the roots of the behavioral health crisis on city streets
requires us to go back to the 1950s, when the federal government
buoyed by the promise of psychiatric medicine to regulate serious mental
illnesses began pushing for patients to be treated in community-based
settings instead of restrictive, expensive, large-scale institutions.
(With the passage of Medicaid, in 1965, it also stopped reimbursing
states for many patients cared for in so-called institutes for mental
disease.) California began shuttering many of its mental hospitals, a
practice that accelerated under Republican Gov. Ronald Reagan, who in
1967 signed a law called the Lanterman-Petris-Short Act that
significantly restricted the governments ability to detain and treat
mentally ill people against their will in conservatorships.
Deinstitutionalization enjoyed broad public support due to a desire to
end the horrific abuse and inhumane conditions many patients endured in
warehouse-like mental hospitals, such as the one depicted in Ken Keseys
1962 novel One Flew Over the Cuckoos Nest. Unfortunately, those good
intentions largely didnt translate into coherent policy alternatives.
Adequate federal and state funding for community-based treatment centers
never materialized. Meanwhile, starting in the 50s, California began
shifting responsibility and financing for many mental health services to
its 58 counties resulting in a decentralized, patchwork system that
advocates contend was never adequately funded.
So where did mentally ill people previously housed in state hospitals
end up? On the streets and in jails and prisons, which became and
remain our states primary mental health facilities, albeit ill-equipped
to handle that role. A San Jose State study determined that of the
19,000 seriously mentally ill people California incarcerated in 2015,
nearly 14,000 were there because state hospitals closed. As of this May,
over half of the more than 96,000 inmates incarcerated in state prisons
were being treated for varying levels of mental illness, state data
shows.
Indeed, many of Californias most troubled residents receive care only
after entering the criminal justice system: More than 90% of the nearly
7,000 patients in Californias five remaining state hospitals were sent
there by either the criminal court or prison systems after being accused
or convicted of crimes related to their mental illness.
Now, California is in the midst of another wave of
deinstitutionalization this time of its carceral system. Following a
2009 federal court order to reduce the population in its overcrowded
prisons, the state in 2011 shifted the responsibility for many
non-serious, non-violent and non-sexual offenders from state prisons to
county jails and probation offices. In 2012, voters approved Proposition
36 to reduce prison sentences for certain repeat offenders. In 2016,
voters greenlit Props. 47 and 57, which reduced penalties for certain
lower-level drug and property offenses and empowered the state prison
system to expand credit-earning opportunities for inmates, respectively.
As state Democrats continue to pass laws to reduce criminal sentences
and prevent incarceration, Gov. Gavin Newsoms administration is working
to shutter four prisons and Democrats in the state Assembly want to
close five more by 2027. Newsom is also seeking to transform some
prisons, including San Quentin, into rehabilitation and education
centers to better prepare inmates to return to society.
Innovative strategies to improve Californias criminal justice system
which has one of the nations highest recidivism rates are sorely
needed. But the state is also making the same mistake it made in the
60s: dismantling a system albeit one thats deeply flawed without
first building out an improved alternative.
Consequently, released jail and prison inmates with profound mental
health needs are often left to rely on a behavioral care system that has
little room to help them. According to a comprehensive 2021 study of the
states mental health infrastructure by the non-partisan think tank
RAND, California lacks space to meet demand at all three main levels of
care acute, highly structured, around-the-clock medically monitored
inpatient care that aims to stabilize patients who cant care for
themselves or risk harming themselves or others; subacute, inpatient
care with slightly less intensive monitoring; and community residential,
staffed non-hospital facilities that aim to help patients with
lower-acuity or longer-term needs achieve interpersonal and independent
living skills. Excluding state hospital beds, California is short about
2,000 acute beds and 3,000 beds each at the subacute and community
residential levels, RAND estimated though woefully inaccurate and
incomplete data makes it difficult to determine the states actual bed
totals.
This lack of infrastructure has contributed to systemic bottlenecks,
leaving some individuals whose condition has improved stuck in
high-security facilities where they no longer belong, while others with
severe needs end up in lower-level settings where they can hurt
themselves or others. This mismatch is exacerbating burnout, trauma and
turnover in Californias already understaffed mental health workforce.
And its leaving far too many of Californias sickest residents with
nowhere to go, fueling the homelessness and drug addiction crises on our
streets.
A clogged system
Dr. Maria Raven, chief of emergency medicine at UCSF Medical Center,
outlined exactly how these bottlenecks create chaos in San Francisco.
When people on 72-hour psychiatric holds are brought into Ravens
emergency room for evaluation and stabilization, theyre supposed to be
placed in locked private rooms. But those often arent available,
forcing some patients to be held in overflow rooms or hallways. Where
they go after that is an open question. Many people, especially those
who dont have private insurance, spend days or weeks in the emergency
department which is far from a therapeutic environment waiting for
an inpatient bed to open up.
If these individuals were open to possibility of receiving prolonged
treatment before entering the hospital, Raven and mental health
advocates said, getting stuck in this bottleneck often sours them on
that prospect.
One reason inpatient beds are so scarce: Many are clogged for years at a
time by people on conservatorships awaiting placement in a state
hospital. Because these hospitals are among the few facilities in
California that will accept patients regardless of their criminal
background or medical condition, theres a massive waiting list to get
in. As of January 2021, about 1,600 people deemed mentally incompetent
to stand trial were stuck in county jails because they had yet to be
placed by the Department of State Hospitals, according to a report from
the nonpartisan Legislative Analysts Office. Meanwhile, as of August
2019, more than 200 people on conservatorships had been waiting an
average of about one year to be admitted to a state hospital, a 2020
state auditor report found.
Simultaneously, the lack of facilities willing or able to accept
improved patients meant that as of January 2020, 138 conserved people
were being treated in state hospitals despite the departments
recommendation that they be discharged to lower levels of care,
according to the state auditor.
What does that mean for San Francisco? According to longtime city social
worker Rachel Berman, because its untenable to have people sitting in
the psych units waiting six months, a year, two years for
conservatorship and placement, many San Franciscans who are gravely
disabled or who pose a risk to themselves or others are often just
discharged.
In other words, they end up on the street, or in facilities that arent
prepared to care for their complex needs contributing to dangerous
conditions in city shelters and single-room-occupancy hotels that can
prompt homeless people to reject placements there.
Californias responsibility
Jason Elliott, Newsoms deputy chief of staff and homelessness czar,
said the administration recognizes the need for more treatment bed
capacity. He pointed to the governors proposal to put a 2024 ballot
measure before voters that would require counties to redirect some
existing tax revenue earmarked for mental health services into buying,
building, renovating or subsidizing housing for vulnerable clients. The
proposed measure would also authorize billions of dollars in bond
funding to build community residential facilities to serve thousands of
mentally ill residents, including those struggling with homelessness and
substance abuse. Separately, the Newsom administration has earmarked $3
billion for building homes for people suffering from severe behavioral
and physical challenges.
The whole system is gummed up, Elliott said. When you widen the
aperture, more people can move through, you create throughput. And that
helps solve some of the problem
which is people getting stuck.
But more infrastructure alone wont solve the problem. Thats because
providers often refuse to accept patients, like Bill Gene Hobbs, with
criminal records and/or a history of violence, even when spaces are
available.
The RAND report found that more than two-thirds of Californias
community residential facilities cant place people with criminal
records particularly those with arson or sex offender convictions
typically because of the complexity of their needs, liability and risk
concerns and their type or lack of insurance coverage, said Nicole
Eberhart, one of the reports co-authors. This prevents subacute
facilities which had an average occupancy rate of 98% in 2021 from
sending improved patients to community residential facilities. This, in
turn, prevents subacute beds from opening up for improved patients
transferring out of acute facilities. And it means highly in-demand beds
are going unused: Community residential facilities had an average
occupancy rate of about 87% in 2021.
Another roadblock: More than 50% of psychiatric facilities at all levels
of care cant place people with serious co-occurring conditions, such as
dementia or a traumatic brain injury, largely because of the complexity
and specialization of care required, RAND found.
Cities like San Francisco cant clear these roadblocks on their own;
they need the state to meaningfully intervene.
One way California can help is to incentivize facilities to take on
challenging clients by increasing reimbursements through Medi-Cal, the
states low-income health insurer that covers one in three residents.
Additional funds would not only help providers offset some of their
liability concerns, but also help them recruit and retain highly skilled
workers and allow them to better serve patients with complex needs. As
UCSFs Raven put it: [Existing] reimbursement just is not good enough,
clearly, because if it were better, then
these places that have (open)
beds would be taking these patients.
Reimbursements for behavioral health providers are set to go up on July
1 as part of CalAIM, Californias ambitious multi-year effort to
radically reform Medi-Cal. Through CalAIM, the state is also rolling out
a first-in-the-nation program to allow eligible jail and prison inmates
to access coverage up to 90 days before their release so they can be
connected to necessary medical and behavioral health care and enrolled
in social services without any gaps. Its covering up to six months of
rent or temporary housing for people leaving institutional settings who
are at risk of homelessness. And its investing in community-based
alternatives to state hospitalization for felony offenders found
incompetent to stand trial.
Mark Ghaly, secretary of the California Health and Human Services
Agency, told the Editorial Board he hopes these changes will be the
beginning of California turning the corner on mental health. But, he
said, Ill remind you this system has been this way for decades. Its
going to take a minute to flip it a bit.
As big and bold as CalAIM is, however, it doesnt adequately acknowledge
the states responsibility to improve care for severely mentally ill
people involved in the criminal justice system. Other countries,
recognizing the unique challenges posed by this specific population and
the higher level of resources and coordination required, have pursued
models California should seriously consider implementing.
Australia, for example, has developed a comprehensive data-gathering
system that helps policymakers determine when and where to invest in new
mental health infrastructure. Using that framework, the state of South
Australia realized it needed to increase the supply of psychiatric beds
for a few key groups, including those involved in the criminal justice
system. A 2018 study reviewing South Australias policy concluded that
U.S. states should also increase their supply of publicly funded beds
including in state hospitals to adequately care for people with severe
mental illness, especially for those caught up within the criminal
justice system.
State Sen. Susan Eggman, D-Stockton, is currently carrying a bill to
create an online database of mental health and substance abuse treatment
beds. Expanding the state hospital system, however, is likely a no-go in
California.
We really want to make sure that
as the governor is trying to close
prisons, were not overbuilding a prison complex by another name,
Elliott said, adding that as the state builds more beds at lower levels
of care it will by definition create more capacity in state hospitals.
That, however, will hold true only if those lower-level facilities
agree to accept patients with criminal backgrounds. Given their historic
reluctance to do so, California may need to develop facilities
specifically designed to treat mentally ill people involved in the
criminal justice system.
Its an approach that has shown promise in Italy, which after closing
its state mental hospitals oversaw the development of locked regional
community facilities focused on rehabilitating people who had pled not
guilty to crimes by reason of insanity. A 2020 study found that 65% of
the 1,580 patients admitted to the regional facilities between April
2015 to June 2019 were discharged meaning a considerable number of
therapeutic measures for these patients were successful. Still, Italys
system is facing its own bottlenecks, with waitlists hundreds of
patients long and many providers dealing with burnout and trauma.
Italys example shows us the potential of a more compassionate,
state-led system of care laser-focused on the hardest-to-treat
populations. But its also a reminder of the danger of change without
adequate investment. California needs significantly more facilities at
all levels of care that can do what right now essentially only state
hospitals can: accept and treat patients regardless of their criminal
background, medical conditions, specialized needs or insurance coverage.
If California falls short of that mandate, any changes it makes to its
mental health system will be nothing more than a Band-Aid on a gaping
wound and the streets of cities like San Francisco will continue to be
mired in misery that they cant fully overcome on their own.
https://www.sfchronicle.com/opinion/article/california-mental-illness-hea
lth-18136221.php