Published on 9/16/20
When Darrell Steinberg first ran for the state Assembly in 1998, he made mental health the bedrock of his legislative agenda. Shortly after he took office, the former Sacramento city councilman introduced AB 34, which initially provided $10 million to fund pilot projects for community mental-health programs.
The bill marked the first significant state investment in an increasingly troubled mental health system in decades, resulting in what Steinberg called “the beginnings of real success, with decreased hospitalizations and reduced homelessness.”
More legislation would follow to expand on the success of the pilot programs, culminating in 2004 with the landmark Mental Health Services Act (MHSA), passed by voters as Proposition 63. The so-called millionaires’ tax – a 1 percent surcharge on taxable income over $1 million – has since raised billions for community mental-health care in California.
By then, Steinberg was termed-out in the Assembly and running for the state Senate, which he later headed as Senate President from 2008 to 2014. A lawyer, he worked in private practice, and founded the Sacramento-based nonprofit Steinberg Institute in 2015 to “dramatically raise the profile and increase the effectiveness of mental health policy-making in California.” He returned to local government when he was elected mayor of Sacramento in 2016.
As Sacramento faces an increasingly serious crisis in homelessness and mental illness, with thousands of citizens wandering the streets, many pitching tents in front of City Hall, Steinberg has continued to press for major local and state mental-health reforms. The COVID pandemic has further decimated government resources, and massive national outrage over police misconduct has sparked continuing protests, mostly peaceful but sometimes erupting in violence.
Steinberg, 60, has also advocated redirecting – not de-funding – police budgets to better respond to mental-health crises, pairing clinicians and social workers with officers to help de-escalate potentially volatile 911 mental-health calls.
In a Sept. 3 interview with Capitol Weekly, Steinberg responded to a wide range of questions about his decades of mental-health advocacy, past and current state legislation, local programs and future plans. This interview was edited for length and clarity:
CW: The recently concluded legislative session saw passage of several important mental-health bills, which have been described as “historic.” The principal bill in the Steinberg Institute package was a long-awaited “parity” bill. While parity laws have been part of state and federal law for years, critics say health insurers have found ways to deny care for mental health and substance abuse. SB 855 aims to change that, and improve enforcement. What does that mean for the estimated 13.4 million Californians who get insurance in the commercial market or from employers?
Steinberg: From my own personal perspective and history, I’ve always strongly supported the parity bills, but most of my focus over decades has been on the public side of the mental health system — MHSA, AB 34, SB 82 — all to strengthen services and to ensure that prevention and early intervention were hallmarks of our public system. It’s crystallized for me over the last couple of years, that the struggles we experience on the public side are in no small part due to the lack of parity. There is a discernible cost shift that goes on, where the health plans don’t cover the variety of innovative approaches that the public side covers. The end result is that the public side has much more demand than the resources available for those who need the help.
CW: And some families have even dropped private insurance in order to qualify for more comprehensive mental-health services under Medi-Cal?
Yes, that’s exactly what I’m talking about. Of course, mental health has thankfully become a bipartisan issue. Regardless of how one approaches the discussion [and] the cost to taxpayers, the resources in the public system can never keep up with the need. In part, it’s due to the fact that we have all these other systems –commercial pay and medical managed care — where the rules are different, where parity is elusive in reality.
This bill is a fundamental shift in several ways. It increases the diagnoses that have to be covered under the parity law. I have a friend, a co-worker with a child whose real-life struggle illustrates what happens for thousands of families. This young girl has an eating disorder and qualifies for the highest levels of care. [Her family’s health plan] helps her to gain weight so that she physically gets out of the danger zone – temporarily — then they immediately step her down (reduce services). And she immediately loses weight again, because it’s a mental-health issue.
The health plans, I’m sorry, they do a lot of good work, and certainly keeping an eye on cost is important. I get that. There is not an infinite amount of money. But in mental health, people get pulled from pillar to post in times of great crisis. . .[Insurers] aren’t required to cover prevention, they don’t cover wraparound services, and they get to define medical necessity. This bill is a big deal. It has the potential to change the whole paradigm around getting care when you have insurance. If we can genuinely infuse parity in commercial pay and managed care, it will then allow the public system to care for those who don’t have insurance and need the public system. We’re really pleased that the bill passed with bipartisan support and hope the governor will sign it.
CW: Do you think the governor will sign it?
Steinberg: I learned long ago not to predict those things, but I know he is a deep believer in improving mental health. He devoted all of his state-of-the-state address before the pandemic to mental health and homelessness.
CW: Are there ways the insurance companies can get around the parity law? Reportedly, some insurers can be very creative in that regard. But there will also be additional staff in the state Department of Managed Care, which will make enforcement more robust?
The willingness to enforce is as or more important than the words in the statute, for all the obvious reasons. Of course, there are ways clever folks can try to work around laws, but if there is a willingness to enforce the letter of the law, and the spirit behind it, and the message gets out there, that is so important. You can’t enforce compliance for everyone. But if you have a willingness to enforce, it begins to change the lives of those who are trying to get help for their loved ones.
CW: Another bill, SB 803, would finally establish a peer-certification system in California, which is one of only a few states in the country without such laws. This has been one of your key legislative proposals for several years now, and previous bills have been passed but were vetoed. Are there any assurances that Gov. Newsom will sign the bill this year? And, if so, what will that do for mental-health care in local programs? Why is peer support so important? And why has it taken so long to pass a bill?
Steinberg: It’s been so long that I don’t even remember whether I introduced it. . .When you look at the experiences of other states on peer services, the people in need get help. They get help earlier. Peers know this, and people in the field know this — that there is no better way to heal than to have the help of someone who has suffered themselves.
And the other obvious point: We don’t have enough mental-health professionals. How can we deny the ready opportunity to increase access? This bill met the fiscal challenge directly (by having the counties) opt-in and decide whether to pay the federal (matching) funds. The state cost is $1 million to set up the infrastructure statewide [using] MHSA administrative funds over two years. The opt-in was an amendment to get it through. Sometimes that works well, sometimes not.
There is a larger issue in play here. We have an opportunity to democratize mental health. I wrote about my late grandmother (in an op-ed for the LA Times). She was not trained or certified, but even as she was disabled, she was calling people who were lonely and shut in. We can all be a peer. We could use a different word, which is friend. To actually certify and train people with lived experience, not only helps them because they’re giving back, but it’s the most powerful thing for people who are hurting, [to know] that they are not alone and that other people have lived through it. . .It’s common sense here, but the system does not often enough acknowledge what is basic and what actually works and then build upon it. The peer movement is a very powerful one, and it’s largely volunteerism — as opposed to harnessing the power of people with lived experience to help others.
CW: Major police reform proposals largely failed this year, despite national protests of police misconduct. While you don’t favor “de-funding” the police, you have said more needs to be done to improve law enforcement response to mental-health crises – which often end badly — utilizing mental-health professionals instead of police (or paired with officers) to respond to calls. The Sacramento Police Department last year hired a licensed clinical social worker, Bridgette Dean, to supervise the Mental Health Unit in the department, which provides training and assists officers in responding to police calls (Dean is now the interim director of the city’s new Office of Community Response). I know you don’t run the Police Department, although you do consult regularly with Chief Daniel Hahn. What can the mayor do to improve police response in mental-health crises?.
Steinberg: To Chief Hahn’s credit, he’s ahead of his time in pairing police with social workers. My [police reform] initiative takes it to the next step. Most of the innovation is at the local level. It’s not an alternative to de-funding, but it’s systemic change over time that people are looking for. It redefines what we expect of police officers in our society. And it’s one area where we can find common ground among combatants on the issue. No matter what one thinks of the police, they are the first and last resort, the first responders, and they’d rather not be responding to all of these calls. They’re not trained to deal with homelessness or with a mental-health crisis.
For a person in a mental health crisis, seeing a person with a uniform and a gun can exacerbate the problem. The real answer, in my view, is not to defund, but to redefine what we expect of police officers. And to back it up with where the money goes, how we fund public safety in the broadest sense. We will actually shift resources to a new unit, the Office of Community Response, with non-law enforcement response to as many of these non-law enforcement calls that we can. The art is in how it is done. In some instances — domestic violence for example, that’s a crime — it’s important that officers accompany [clinicians] to a call. But then there is the handoff so that victims can get help, and perhaps we can prevent the second, third, fourth and 10th calls.
I’m very excited about this initiative. It’s different from saying we’re going to cut X percent of our police budget. We’re very serious about it, and the new interim director of the Office of Community Response, Bridgette Dean, is passionate and experienced in this area.
CW: Some of the protests recently have devolved into violent confrontations, destruction of property, looting, often by second waves of protestors, following peaceful protests and involving individuals described as anarchists or “outside agitators.” You’ve engaged directly in conversations with protestors, including a recent, intense discussion, filmed by TV news crews, when you were approached leaving a restaurant by protesters.
Just another day as mayor. . .Some say it was a mistake to show up. I’m always going to show up. They have the right to say whatever they want. I continue to try to [show up]. As long as people are peaceful and nonviolent, they have the right to criticize me any way they want. I continue to try to elevate the discussion. . .
There are definitely people coming in from outside the community. I draw a very clear line. We uplift and uphold people who take to the streets to express their anger so long as they do so peacefully and nonviolently. But those who come in from outside or live here in the city, with bats and spray paint, it’s not acceptable. We have to differentiate between the two. It’s a dilemma for people in leadership, and we try to be thoughtful about it. I stick to that line. I think that is what most people believe.
CW: You recently wrote, with Dr. Jonathan Sherin, mental health director for LA County, an op-ed for the LA Times on the “antiquated” Lanterman-Petris-Short (LPS) law that has governed mental-health care in California for more than half a century. None of the mental-health bills that passed this session seriously addressed LPS, which has been called the “third rail” of mental-health policy in California. Why is it so difficult to make substantive changes in the law?
Steinberg: I’ve always believed that involuntary commitment and Laura’s Law (Assisted Outpatient Treatment in California) are a necessary part of the system at the very end of the continuum. Voluntary treatment and services are always a better way to start and to persist with. But there comes a point, and it is most clearly seen with people who are chronically homeless or they live for years in their parents’ back bedroom. Everyone suffers because they don’t seem to have any answers.
The LPS law ought to mean what it says, and it doesn’t. No one can argue with a straight face that someone who has been on the streets for years and living with severe mental illness, is not mentally disabled. It defies common sense. There is a lack of effective services, a lack of sufficient prevention and early intervention. And it’s all voluntary. We see the results.
CW: You and Dr. Sherin mentioned the “laudable” goals of LPS to “try to right the horrific injustices of prior decades”—the grotesque human rights abuses of the state mental hospitals, which have been mostly closed. But you also wrote that current conditions require updates to the 1967 law, particularly in the definition of “gravely disabled.” What changes do you recommend?
All sides of that debate are living with the trauma of a system (pre-LPS) that also did not work for people who deserved better. . . .That does not mean that what we have now is helping as many people as it must and it should.
Whether or not one believes in a right to shelter — and an obligation for people to take shelter and housing if offered — the fact of the matter is we have a completely voluntary system on both sides. When something is optional or voluntary on either side, it doesn’t get the attention and the priority and focus that it needs and deserves. I’ve said this for a year and a half. . .Our legally enforceable mandate, AB 3269 by (Assemblyman David) Chiu (D-San Francisco), did not pass. But I’m coming right back with this idea, that some form of legal obligation from the government — and the consumer, if it’s offered with dignity — be part of this conversation. And LPS is part of that.
CW: As the author of the landmark 2004 Mental Health Services Act, Prop. 63, you’ve said some changes need to be made in MHSA. Explain.
Steinberg: This was one of the casualties of COVID. We were very focused on an MHSA refresh, and the administration was very focused, but it obviously got overwhelmed. We will go back next year to resume the work to refresh MHSA. So much about the MHSA is working well, but what we all want is a more outcome-based set of investments, where we can actually show how this money is being used, catalyzed with other public and private resources, and delivering results around the most serious consequences of mental illness. We don’t have to radically change it as much as we want to refresh it, to make sure that the county and the state are accountable for better results.
CW: The California State Auditor recently issued a scathing report on the state’s mental-health system, recommending major changes. While she did not recommend changing the basic structure of LPS, she did call for major improvements in delivering follow-up care to people who are released after LPS mental-health holds, often ending up on the streets, or in jails and prisons. You’ve said that the auditor’s report addressed only a small portion of mentally ill people needing help – those who are detained in involuntary holds or find their way to a hospital ER. Could you elaborate?
Steinberg: I actually thought there were parts of the audit that were really important and strong, and reinforced much of what we already know — that no matter what you do with the statute, if you don’t have a real system of care, services and treatment for people that is more easily accessible, then even an involuntary hold of some kind is just going to be a designation. [The audit] was very good and helpful, but it was incomplete. It only looked at the smaller cohort. It didn’t look at the definition of grave disability. It was a good piece of work, but there is more work to do.
Editor’s Note: Sigrid Bathen is a Sacramento journalist and former Sacramento Bee reporter who taught journalism at Sacramento State for 32 years. She has long covered mental-health issues, for several publications, and her writing has won numerous awards. She has covered health care, education and state government for Capitol Weekly since 2005. Her web site is www.sigridbathen.com. She can be reached at firstname.lastname@example.org.