Gov. Gavin Newsom introduced a plan in early March that would compel treatment for as many as 12,000 people with severe mental illness and drug addiction — including many experiencing homelessness.
While some are on board with the still developing framework, civil rights groups and homeless advocates say they’re worried the proposal is a step backward for the rights of some of California’s most vulnerable people.
The so-called CARE Court plan, an acronym for Community Assistance Recovery and Empowerment Court, has garnered support from mayors and state lawmakers who say it could address a portion of California’s growing homelessness problem while helping fix its broken and costly mental health system.
Supporters say the current system cycles homeless people struggling with mental illness and addiction through jails, hospitals and psychiatric centers only to send them back to the streets or shelters without rehabilitating them, largely because treatment is voluntary.
They say that must change.
“Why when it comes to providing treatment for people living in squalor on our streets is it a voluntary and optional act of government? I don’t get it,” Sacramento Mayor Darrell Steinberg said during a March roundtable where mayors from Fresno to Los Angeles to San Jose spoke in favor of Newsom’s initiative.
But some homeless advocates say Newsom’s plan lacks a clear guarantee that participants would receive housing, and a prominent county government association warns it could create a financial burden for local governments.
Meanwhile, civil rights groups say CARE Court would be a reversal in California’s move away from severe restrictions on people with mental disorders, following the state’s notorious era of institutionalization during the 20th century.
“We see it as forced treatment,” said Lili Graham, an attorney with the advocacy group Disability Rights California. “And that is that antithesis of what underlies disability rights — the right to self-determine care.”
While acknowledging the plan would compel treatment, Newsom and the plan’s backers say CARE Court could also prevent people from ending up in more restrictive settings like conservatorships or behind bars. Even so, under the governor’s plan, a civil court judge could refer someone who refuses treatment to a year-long conservatorship, under which they would lose the right to make decisions about their own well-being.
Still, to change the status quo across the state, Newsom says both government and individuals must be held accountable.
“What the hell are we doing about those that are suffering out on our streets and sidewalks?” the governor said last week during a press conference at Napa State Hospital, a psychiatric hospital that serves patients committed through civil and, mostly, criminal court action. “When can we hold ourselves to a higher level of accountability?”
As the debate continues over CARE Court, here are answers to some key questions about the proposal:
Who would CARE Court serve?
The Newsom administration estimates between 7,000 and 12,000 Californians would be eligible for CARE Court, a small fraction of the state’s total homeless population.
The most recent federal count conducted in January 2020 found California had approximately 161,000 people experiencing homelessness. Researchers and advocates believe that number has only grown during the pandemic.
A CARE Court fact sheet says the program “is not for everyone experiencing homelessness or mental illness.” Instead, it “focuses on people with schizophrenia spectrum or other psychotic disorders who lack medical decision-making capacity — before they get arrested and committed to a State Hospital or become so impaired that they end up in a Lanterman-Petris Short [LPS] Mental Health Conservatorship.”
How would it work?
CARE Court would be a referral-based program. It would allow first responders, law enforcement, behavioral health providers and family members to refer people struggling with addiction and mental illness, according to the Newsom administration.
Under the plan, a judge would appoint that person a public defender and order a clinical evaluation to determine whether they meet the criteria for the program.
If they do, the judge would order a “CARE plan” that would outline treatment and medication for up to 12 months. The plan would be developed by county behavioral health specialists, the participant and a newly established position called a “supporter,” who would help the participant “understand, consider and communicate decisions,” giving them the tools to make self-directed choices to the greatest extent possible, according to the administration.
The judge would review the plan, hold status hearings and could extend treatment by an additional 12 months.
The program would include what the Newsom administration calls “a housing plan” for participants who need it. But it would be up to the judge to order a local government to provide housing, as not all participants are expected to be homeless.
Some advocates for people who are homeless say there should be a stronger guarantee on housing and questioned the effectiveness of forced treatment.
“We’re concerned that this proposal seems to compel participation in treatment before the individual is living in permanent stable housing,” said Mari Castaldi, a legislative advocate with Housing California, which supports policies to end homelessness. “And the proposal doesn’t really point to how people experiencing homelessness will access the housing they need to stabilize.”
In response, Jason Elliott, Newsom’s top advisor on homelessness, said “every effort would be made to get them indoors.”
If a participant does not successfully complete their CARE Plan, the judge would have the authority to refer them to a conservatorship, according to the governor’s framework. If they had been referred to the program from jail or prison and they failed to complete it, the judge could order them back to incarceration.
Will forced treatment be effective?
Bob Erlenbusch, who teaches a course on advanced behavioral health at Sacramento State University, argues that you can’t compel treatment for someone who isn’t ready to accept help.
“You might take people off the street and hide them away, but that doesn’t mean they’re getting better,” said Erlenbusch, who is also executive director of the Sacramento Regional Coalition to End Homelessness.
Critics have pointed to a 2014 study from the National Institutes of Health which concluded that empirical evidence doesn’t support the use of coercive treatment and that more research is needed.
But Newsom administration officials say California’s behavioral health treatment has evolved and can effectively and humanely treat mental illness and addiction. They say that care is nothing like the state’s history of overcrowded state hospitals handing out extreme treatments like lobotomies and forced sterilizations.
“It’s not a mystery how to treat these individuals,” said Dr. Katherine Warburton, a forensic psychologist and medical director of the California Department of State Hospitals, speaking at the governor’s press conference in Napa. “We have the science. We have the medications. We know that intensive psycho-social support, housing and medication can keep these people connected to their families and in their communities. And CARE Court has the potential to give us that.”
How much would it cost?
Newsom has yet to release the plan’s price tag.
At his press conference in Napa, he said the same funds that are now spent cycling people through hospitals, jails and courtrooms without addressing underlying mental health and addiction problems, could be spent on CARE Court.
“We’re already spending the money,” the governor said. “Money is not the issue here.”
Not everyone agrees.
California’s 58 county governments would be responsible for providing mental health treatment for CARE Court participants. Historically, those services have been underfunded, said Graham Knaus, executive director of California State Association of Counties.
“Counties stand ready to collaborate to assist participants, but caution that the behavioral health infrastructure is just starting to come out of decades of inadequate funding and support and housing remains elusive,” Knaus said in a press release March 3, the day Newsom unveiled the CARE Court framework.
In a March 26 letter to the Newsom administration, Knaus reiterated his concerns that CARE Court could be a financial burden for counties without “sustainable funding.”
The initiative could increase caseloads for county public guardians and conservators “who are funded entirely with county general fund, [and] are struggling to keep up with current caseloads of more than 60 clients per worker, double the recommended caseload for this type of intensive casework,” he wrote.
Elliott, the governor’s advisor on homelessness, said the administration will propose new spending in the governor’s revised May budget to pay for the cost of the court itself, including public defenders, bailiffs and administrative expenses.
‘A lot of money in the system right now’
Elliott said the state could pay for CARE Court’s treatment and housing costs with parts of the $12 billion Newsom approved for homeless housing and supportive services in last year’s state budget. That money includes $3 billion to create 22,000 behavioral health housing beds for people struggling with mental health disorders.
The governor also could use money from the voter-approved Proposition 63, or the Mental Health Services Act. Better known as “the millionaire’s tax,” the measure was authored by then-Assemblyman and current Sacramento Mayor Steinberg and levies an additional 1% income tax on personal incomes above $1 million.
That fund is expected to produce $3.8 billion this year, according to state officials.
Finally, Newsom could also draw from $2 billion in additional homeless aid he proposed for this year’s budget if the Legislature approves the spending plan this summer.
“There is a lot of money in the system right now,” Elliott said.
But as Phebe Bell, behavioral health director for Nevada County and the president of the County Behavioral Health Directors Association told the Los Angeles Times, it takes time to build that infrastructure.
“Turning money into beds takes years in my experience,” Bell told the newspaper.
‘Time for a paradigm shift’
Given the large amount of available funds, Castaldi of Housing California said the state should prioritize making existing mental health and drug treatment programs available and accessible, not creating a new compulsory system.
“We’re concerned about compelling individuals through a legal process with implied threats of referrals to conservatorship or incarceration, knowing that we do not at this time have the resources at the scale needed to provide those services on a voluntary basis,” she explained.
Elliott acknowledged the state’s behavioral health system has historically been underfunded, but said that is changing. On the point of making treatment mandatory, he said the Newsom administration must “agree to disagree” with advocates like Castaldi.
“We need some accountability in this system,” Elliott said. “There’s accountability [within the CARE Court plan] on government but it’s also accountability on individuals. People are frustrated that we haven’t been able to make more of a dent, and it's time for a paradigm shift.”
Newsom said he expects to release more CARE Court details in April. He is asking state lawmakers to approve the plan as part of the state budget. If that happens, it could take effect as early as July.
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