California wants to force people into mental health care. Advocates say it will backfire

<span>Proposition 1 would raise $6.4bn for housing and treatment for people with mental health and substance use disorders.</span><span>Photograph: Anadolu/Getty Images</span>
Proposition 1 would raise $6.4bn for housing and treatment for people with mental health and substance use disorders.Photograph: Anadolu/Getty Images

California’s Proposition 1 – the only statewide measure on the ballot – would significantly restructure California’s mental health system.

It is also one of the most complex and convoluted measures voters have had to decide on in recent years. The full text of the state’s 112-page proposition takes up 68 pages.

The measure has two parts. First, it would raise $6.4bn over 20 years to build more housing and treatment facilities for people with mental health and substance use disorders. It would also enact new requirements on how the state’s mental health budget would be spent – redirecting about a third toward housing and rental assistance for unhoused people with serious mental illness or addiction, and another 35% toward treatments for that population.

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California’s governor, Gavin Newsom, who proposed the measure as a crucial part of his plans to solve the state’s dire homelessness crisis, has said it would “prioritise getting people off the streets, out of tents and into treatment”. Opponents, including disability rights activists, mental health advocates and the American Civil Liberties Union, countered that it would take money away from community-based preventative mental health programs to finance locked-door psychiatric institutions and involuntary treatment.

“It’s good politics, as Newsom positions himself to run for president in 2028,” said Samuel Jain, a senior policy attorney for Disability Rights California, an advocacy group. “It’s not good policy.”

The bond measure was not controversial until late last year, when last-minute amendments to the bill placing it on the ballot stripped language preventing the funds from being used on involuntary confinements. The changes came hours before it was too late to change the legislation, said Jain, who added: “It came as a really big surprise.”

The result, Jain said, is a hefty, opaque ballot measure that lumps housing for veterans and unhoused people and treatment programs for people with severe mental illness and substance use disorders alongside funding for programs that could facilitate coerced institutionalisation.

Critics have also pointed out that the $6.4bn bond would only fund about 4,350 new homes for people, according to the state legislative analyst’s office – which is hardly enough to shelter California’s estimated 180,000 unhoused people.

Meanwhile, the Yes on Prop 1 campaign, backed by healthcare companies such as Sutter Health and Kaiser Permanente and unions backing the state’s prison guards and construction workers, have amassed about $14.3m to sell the measure, focusing on how the program would help veterans and the unhoused. The No campaign has raised just about $1,000, according to campaign finance records.

But taken along with other major mental health programs that Newsom and legislators have championed, advocates worry that Prop 1 will further efforts to institutionalise and lock away unhoused people. The governor’s other landmark mental health reforms include the Care court program, which will empower families, healthcare providers and outreach workers to ask state courts to compel people with certain severe mental disorders into treatment programs designated by local governments, and SB43, which expands the group of people who can be placed in involuntary psychiatric holds or forced to undergo medical treatment to include people with serious mental health and substance use disorders who are deemed unable to provide for their own personal safety or medical care.

“In the 1960s, we began the process of shutting down our psychiatric hospitals,” Newsom said at a Thursday rally promoting the proposition. But as the state got rid of its psychiatric beds, it did not provide enough investment in community programs and care homes as alternative treatments, he continued, saying: “Is it any surprise what we’re experiencing and those that are struggling and suffering are experiencing? It’s because of our neglect.”

Building more psychiatric beds and treatment facilities may be a comfort to families who have struggled to help relatives with severe mental conditions and substance use disorders, Newsom and other supporters say. But mental health providers and researchers warn that if Prop 1 facilitates involuntary or coerced care, it could ultimately be counterproductive.

“Few who review the existing evidence conclude that on balance, involuntary treatment improves the lives of those who experience it,” said David Cohen, a professor of social welfare at the University of California, Los Angeles, and a former social worker. “It’s literally a Band-Aid solution.”

Being coerced or forced into care can traumatise people who are already contending with deep traumas, he explained. “Being deprived of freedom is maddening. Being robbed of credibility is humiliating,” he said. Though hospitalization or institutionalization are often used to keep suicidal people safe, counterintuitively, studies have found that such patients may be at heightened risk of self-harm after being discharged.

Increasing avenues for institutionalisation and building more locked-door psychiatric and behavioural health facilities could also disproportionately harm Black Californians and other Californians of color, said Jerel Ezell, an assistant professor of community health sciences at UC Berkeley. Black people, who make up about 6% of California’s general population, account for 26% of the unhoused population.“And Black people are over-diagnosed with schizophrenia and other related conditions,” he said. “They’re also more stigmatised or more criminalised.”

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With Prop 1 funding, the state could expand its capacity to clear the streets of the most visibly unwell unhoused people, and funnel them to programs that could do more harm than good. “It’s an optics thing,” he said. “It looks good, to say we’re doing something.” But long term, much more housing and voluntary, preventative programs as well as asylum spaces for drug users are what people really need to recover, he said.

Many of the biggest opponents of Prop 1 are local governments and health workers who worry it will shutter local, community-based, early intervention programs, including ones that provide care for immigrant communities, communities of color and unhoused people.

Decisions about which funding would be redirected would be made by counties if the measure passed, and nobody knows how much money would be cut from which programs. Proponents of Prop 1 argue that those early intervention programs could draw more funding from Medi-Cal, the state’s public health program for lower-income residents, which has recently been expanded.

Rural Placer county, where supervisors voted to oppose the measure, would redirect about $5m from existing mental health and prevention services that are already very scarce.

“Proposition 1 is going to put more money towards building these expensive, locked psychiatric institutions. It’s going to provide grants to for-profit hospitals to actually build those facilities,” Jain said. “And in turn, it’s going to defund cost-effective mental health services in the community.”