Mayor and Board Reach Deal on Mental Health SF

by Jennifer Friedenbach

In a compromise, two competing measures on mental health will not go to the ballot; instead, Mental Health SF will go through the legislative process.  The very contentious process ended in awkward hugs as the city family shared the stage on the steps of city hall in a press conference announcing the deal on November 12, 2019. 

     Supervisors Hillary Ronen and Matt Haney proposed going to the ballot with Mental Health SF, a plan they came up with that moves San Francisco closer towards having universal mental health care by opening up a 24-hour central access center, an office of coordinated care and creates a new oversight body.  Mayor London Breed, stating displeasure with the measure, entered into negotiations with the supervisors and then walked out, even after several concessions were given, stating she did not want said measure to go to the ballot.  

Breed then introduced a nasty countermeasure entitled Urgent Care SF that would increase criminalization.  It would appear on the same ballot and would implement some things that she was already planning on doing in addition to prioritizing enforcement of possession of drugs and putting San Francisco police in charge of homeless outreach teams, street medicine and mobile crisis.  It also had a one-way poison pill that would kill the Ronen/Haney measure if her measure got more votes, but would institute both if the Ronen/Haney measure got more. The entire debacle felt like a “Game of Thrones” episode where mental health consumers are forced to pay the price for political maneuvering.  

In the end however, Breed withdrew her countermeasure and agreed to move Mental Health SF through the Board of Supervisors, instead of going to the ballot. Very few substantive items were compromised in the Ronen/Haney measure, Mental Health SF, except to exclude privately insured people from the measure, which may not have been a bad thing, given the Department of Public Health’s current state of disarray and the lack of faith in their ability to handle much more. 

Here are the key elements of Mental Health SF that was agreed to but still needs to go through Board of Supervisors to be passed:

+          Serves homeless people and uninsured people under 500% of federal poverty level (or making less than $62,450 annually; those with incomes over 500% will pay fee for service), as well as those receiving Medical and HealthySF, but prioritizes homeless people with both substance use and severe mental illnesses. 

+          Creates governing principles from harm reduction approach to low barrier access and customer focused services.  It also mentions involuntary treatment only after other attempts at voluntary services have been made and in accordance with state law.  It also has as a principle that housing must be prioritized to the priority population under Mental Health SF. 

+          Establishes a mental health service center that must be open 24 hours.  As part of the compromise, it will be located at 1380 Howard St., the current service center instead of having a new one at SF General Hospital.  It will bump up the services there – keep the pharmacy but expand the site from treatment referral and wait list management to having more intensive services on-site such as transportation, urgent care, case management, and psychiatric assessment. 

+          Establishes an Office of Coordinated Care to oversee the delivery system.  The functions will include real time inventory of program and service availability, case management including filling the unmet need for intensive case managers (broken down into three levels of care depending on acuity level), coordination with psychiatric emergency services and jail, and data collection.  There is also a marketing component to get the word out. 

+          Creates a Crisis Response Team that hopes to replace police response to folks in psychiatric crisis.  This shall operate 24/7, and will have an ability to field calls directly and through dispatch.  

+          Mental Health and Substance Abuse expansion is called for but not directed, with the idea to eliminate wait times across the system.  A working group will make recommendations for what this should look like. 

+          Establishes an Office of Private Health Insurance Accountability to advocate on behalf of privately insured individuals who are not getting the coverage they need, in conjunction with the city attorney.  This includes the provision of insurance navigators, collecting data, advising folks on resources. 

+          Forms a Working Group to oversee the operation, make recommendations on funding, and issue reports.  This is a split group with 11 seats, six appointed by the board, and five by the mayor. 

Today, folks with severe mental illnesses are not getting their needs met and are frequently used for political gain under calls to lock them up.  In reality, they are locked out of care. In order to turn this around, they need a diverse robust system of care without waits. The Coalition on Homelessness, Street Sheet’s parent organization, is currently conducting a needs assessment of folks with mental health and substance use issues, and the hope is we can utilize Mental Health SF as a catalyst to forge the changes that our folks are calling for.  As of yet, there is no funding attached to this measure, but a side agreement with the mayor includes a signed statement that funds will be found. To do it right, it may mean returning to the ballot for revenue. The mayor plans on putting a bond measure to pay for part of it, and there is talk of a CEO tax to pay for operating costs.  The estimate is this will cost $100 million, but the price to ensure we have enough treatment capacity for all who need it is clearly much higher, given there are 4,000 people identified by the Department of Public Health who are homeless, mentally ill and using substances, and the cost of beds can be as high as $250,000 per year in the very highest levels of care.  Community care is both more effective and a much lower cost than institutions, but there are upfront costs of securing facilities to that as well. Mental Health SF could be key to putting in place a responsive healing client centered system, but a lot more work needs to be done. This must include continuing to push for housing – as this is as important a mental health intervention as any.