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Declaring that moral persuasion and economic incentives aren’t working to bring in people from the sidewalks, Gov. Gavin Newsom’s task force on homelessness earlier this week called for a “legally enforceable mandate” that would force municipalities and the state to house the growing number of homeless Californians. 

The proposal, which came as Newsom kicked off a weeklong tour of the state aimed at drawing attention to the homelessness crisis, urged the Legislature to put a measure on the November ballot that would force California cities and counties to take steps to provide housing for the more than 150,000 Californians who lack it—or face legal action.

Such a measure would require a two-thirds vote of both legislative houses to be brought to voters. California law does not currently penalize the state or local governments for failing to reduce their homeless populations, nor does it force them to make housing sufficiently available to people without it.

But Los Angeles County Supervisor Mark Ridley-Thomas and Sacramento Mayor Darrell Steinberg, who co-chair the governor’s 13-member Council of Regional Homeless Advisors, have been advocating for some sort of enforceable “right” to sleep indoors since the U.S. Court of Appeals for the Ninth Circuit struck down laws against homeless camping. That ruling, which the U.S. Supreme Court let stand just last month, dramatically limited cities’ enforcement options, finding it to be cruel and unusual punishment to prosecute people for sleeping on the street if sufficient shelter isn’t available.

“California mandates free public education for all of its children and subsidized health insurance for its low-income residents. It requires its subdivisions to provide services to people with developmental disabilities and foster children,” the commission wrote in a letter signed by both elected officials. “Yet everything that state, county and city governments do to alleviate this crisis is voluntary. There is no mandate to ensure people can live indoors, no legal accountability for failing to do so, no enforceable housing production standard and no requirement to consolidate and coordinate funding streams across jurisdictions. The results speak for themselves.”

The council’s recommendation stops short of Steinberg’s and Ridley-Thomas’ initial call for a “right to shelter,” which would not only have required cities to provide immediate beds, but also obligated people experiencing homelessness to come inside. But it adds momentum to the strategy of elevating litigation as a tool to accomplish what compassion and money haven’t been able to do.

Newsom, visiting a homelessness program in Nevada County, said Monday he “would lean in the direction” of speedily deploying a legal “obligation” to supply sufficient services and housing, adding that “a number of cities and counties” have volunteered to do demonstration projects over the next several months, “not the next few years.” (Ridley-Thomas later said he would propose such a pilot in Los Angeles County this week.)

“I broadly have been encouraging this debate about obligations,” the governor said, adding that “there’s a distinction between rights and obligations.”

Without elaborating on that distinction, he seconded the task force’s point that many of the state’s responsibilities stem from legal mandates: “We do it in almost every other respect,” Newsom said. “On this issue, we don’t, and I think that’s missing. The question is how do you do it. … This is not black and white. This is tough stuff.”

Municipalities made it clear they would need more clarification.

“A legally enforceable mandate can only work with clarity of who’s obligated to do what, and what new sustainable resources will fund it; that’s the ticket for clear expectations and accountability,” said Graham Knaus, executive director of the California State Association of Counties, in a statement.

Steinberg, meanwhile, called Monday’s proposal an improvement on the original “right to shelter” concept, saying a mandate by any name would still have the force of law. The point, the mayor said, is to give the courts a legal “last resort” to address pleas to supersede political gridlock, just as federal laws have in the past armed judges to combat other social crises.

“It’s analogous to desegregation,” Steinberg said.

The task force’s proposal would let a “designated public official” sue the government for not doing enough to offer emergency and permanent housing to the homeless. A judge could then intervene to force a city to approve an emergency shelter, for example, or redirect budget funds to homelessness services.

The proposal, however, so far lacks specifics on how taxpayers would pay for such a mandate. The letter released by the task force, which includes local elected officials from large and small cities, states that “more state resources will undoubtedly be required,” but includes no estimate.

State and local governments in recent years have poured billions into combating homelessness, only to watch the problem worsen as ever-rising rents drive Californians to the streets faster than they can be re-housed. On Friday, for the second straight year, Newsom proposed more than $1 billion in new state funds to fight homelessness, calling it “the issue that defines our times” in California. But the state’s “point-in-time” homeless count jumped 17 percent between 2018 and last year.

San Diego County Supervisor Nathan Fletcher, a task force member, said leverage is needed.

“We do the things we are required to do first … then for everything else, we try very hard,” said Fletcher. “Absent a legally enforceable obligation, I believe people will continue to try very hard.”

But a legal mandate would arm jurisdictions to tackle “the underlying problem, which is poverty,” rather than appease communities with shelter beds, he said.


Putting the Onus on Government to Provide Housing

Steinberg and Ridley-Thomas floated the idea of a statewide “right to shelter” law last year. Spurred by decades-old litigation, New York state has a “right to shelter” policy that makes its state and local governments legally liable for having emergency shelter beds available for every unhoused person. 

While many credit “right to shelter” for New York’s success in reducing the number of people sleeping on the streets, Newsom and advocates for the homeless have balked at the idea. Some advocates fear it would divert finite funding from permanent supportive housing, which experts say is a more long-term, albeit expensive solution; others worry about cost and potential civil-liberties violations that might arise from requiring a homeless person to accept shelter if it’s available.

“The reason why right to shelter is a mistake is because it diverts resources from the solution, which is housing, not shelter,” said Sharon Rapport, California policy director for the Corporation for Supportive Housing and a member of the task force.

Under the policy proposed by the task force, a local government would be required to develop a plan to house the vast majority of its homeless people within “an aggressive but reasonable period of time.” “Reasonable” is not defined in the letter.

However, Steinberg said that, in the case of Sacramento, “aggressive but reasonable” might mean a 1,500-person annual reduction in the city’s 5,500-plus homeless population, and housing the “the vast majority” within five years.

Advocates on the homelessness issue said more specifics are needed, but applauded the task force’s recommendations as a philosophical pushback, at least, against efforts to criminalize living on the streets.

“Any kind of policies that are promoting locking up people or warehousing people or punishing people for being homeless, the council is saying those policies have been very ineffective in the past,” said Rapport.

The city of Bakersfield recently proposed ramping up enforcement of low-level drug offenses to get people off the streets there, and advocates have expressed concern that the Trump administration’s threats to do something about homelessness in California may involve heavier use of law enforcement.


A Homelessness Czar, but Little on Conservatorships

The task force also called for a single point person on homelessness, a Newsom campaign promise that devolved in his first year into confusion over who, at any given point, was his “homelessness czar.”

Various administration members, including Steinberg and Ridley-Thomas, state Secretary of Health and Human Services Mark Ghaly, and adviser Jason Elliott, have filled the role—so many that last week, Newsom headed off press questions by declaring tartly, “You want to know who’s the homeless czar? I’m the homeless czar in the state of California.”

But the issue of who is actually overseeing the state’s disparate homelessness initiatives—across multiple bureaucracies from prisons to health care—is still pressing, at least according to the homelessness task force. One of their key recommendations would “create a single point of authority of homelessness in state government,” suggesting a high-level official that reports directly to Newsom. Another calls for a comprehensive accounting of existing funding for homelessness, housing, mental health and substance-abuse treatment.

Still other recommendations have already been incorporated into Newsom’s proposed homelessness budget, including a “flexible fund” that service providers can tap for uses from emergency rental assistance to building shelters. The task force also proposed revamping the state’s health-insurance program to draw down more federal dollars for homelessness-related services, a key pillar of the strategy Newsom unveiled last week. Doing so would require a waiver from the federal government.

Oakland Mayor Libby Schaaf, a member of the task force, said that a Medi-Cal reform proposal is key to the the blueprint.

“Housing is health,” she said. “And to recognize that health dollars should appropriately be used to support housing is a very important part of our recommendations.”

More-controversial proposals included an executive order expanding the state’s new rent-gouging law to cover more households, and legislation exempting from environmental review any new housing project for people at risk of homelessness.

California has strict laws that make it difficult to detain mentally ill people against their will for a prolonged period of time. Families of homeless loved ones struggling with schizophrenia or other disorders often blame the Lanterman-Petris-Short Act, a late 1960’s law intended to curb the overuse of asylums, for precluding necessary care. New York’s commitment laws are less stringent.

While Newsom talked vaguely of reforming the law last week, such reforms are conspicuously absent from the task force’s report.

CalMatters.org is a nonprofit, nonpartisan media venture explaining California policies and politics. 

Published in Local Issues

The sightings of James Mark Rippee are all over his sisters’ Facebook account.

Someone spotted him sleeping by a furniture store in Vallejo. Someone walked him to a gas station for coffee. Someone prayed for him at Nation’s Giant Hamburgers.

Rippee, 56, developed schizophrenia after a horrific motorcycle accident more than three decades ago caused a traumatic brain injury and the loss of his eyesight. His delusions range from being an alien, to getting chased by the KKK, to being prevented from collecting his lottery winnings, his sisters say.

In September, he stepped into traffic and was hit by a car, his sisters say; he then developed a brain abscess. After weeks in the hospital and a board-and-care, he walked out. His 62-year-old twin sisters—Catherine Hanson and Linda Privatte—weren’t alerted.

Now they couldn’t find him.

Complicating things further: Hanson is bedridden with blood cancer; Privatte is legally blind and cannot drive. They’ve come to depend on a Facebook community, “Mark of Vacaville,” to be their “eyes and ears” on their brother’s situation.

The existence of the 2,000-plus member group is at once a moving testament to a community’s compassion, and an indictment of a system that often leaves the most vulnerable to fend for themselves.

Why do people as sick as James Mark Rippee sleep on our streets? Some blame laws that prioritize civil rights over forced treatment; others point to an under-resourced and uneven mental-health system that has failed to provide people like Rippee with long-promised care.

Everyone struggles with the same underlying question: What should be done?

“When we allow people to deteriorate on the streets, or interface with law enforcement that leads to incarceration, what are we doing?” asks Dr. Jonathan Sherin, director of the Los Angeles Department of Mental Health. “We’ve lost our compass.”

State lawmakers are watching a controversial new pilot program to expand forced treatment in San Francisco.

In the meantime, families watch in desperation as loved ones cycle between homelessness, emergency rooms and jail cells. Short courses of medication may lead to the quieting of voices, which, in turn, leads to a release to the streets. Often, as in James Mark Rippee’s case, the family is simultaneously shut out of the conversation and blamed for abandonment.

Some of these families are aware of the downsides of involuntary treatment, the miserable side effects of psychiatric medications, and the critical shortage of inpatient facilities. They recognize that conservatorship—in which a court-appointed conservator manages another person’s living situation, medical decisions and mental health treatment—is no panacea, and should be a last resort.

James Mark Rippee himself puts it this way: “I don’t need to be in a locked-up facility. It was like I was a hostage.”

In recent years, Rippee’s twin sisters—Hanson, the red-headed warrior, Privatte, the blonde diplomat—have redoubled their decades-long effort to get him help. They worry their own health problems might someday leave no one to fight for him.

“He is the worst-case scenario of anybody being so vulnerable on the streets,” Hanson said. “Every winter we wonder: Is this going to be the year that he dies?”


In 1967, a law passed that transformed the treatment of people with mental illness in California.

Until then, it had been fairly easy for a family member to call police to force someone into mental health treatment. Conditions in the state hospitals were frequently abhorrent: Patients wore gunny sacks, sometimes bathed just once a week, and were subjected to lobotomies and electric-shock treatments. Too often, people were locked away for life.

Republican Assemblyman Frank Lanterman and Democratic Sens. Nicholas Petris and Alan Short proposed a radical overhaul, which Gov. Ronald Reagan signed into law. When the Lanterman-Petris-Short law took effect a few years later, it established strict criteria for involuntary treatment. It imposed specific timeframes for involuntary confinement and limited involuntary holds to those deemed a danger to themselves or others, or gravely disabled. This included the 72-hour hold that police term a 5150.

But within a few decades, Sen. Petris noticed growing numbers of people with serious mental illnesses appearing on the streets and in jails.

In a 1989 oral history, Petris lamented that while the law had promised funding to treat people with mental illness in the community, Gov. Reagan diverted tens of millions allocated back to the state general fund.

“That took the guts right out of this state money for local treatment,” Petris said. “It emptied out the hospitals, but there was no follow-up treatment. … In this overemphasis to get away from this tyrannical and oppressive system … of incarcerating people so easily, we went overboard the other way.”

Even when funding was available, “Not In My Back Yard” resistance also made it challenging to locate residential and community treatment facilities. In the half-century since, much of the debate about helping people like Rippee has centered on the Lanterman-Petris-Short law. The state auditor is currently examining it; a report is anticipated this spring.

In recent years, several bills in the Legislature have been proposed to modify the law, focusing on redefining the term “gravely disabled.” Rippee’s sisters petitioned and testified last year on behalf of a bill that sought to define “gravely disabled” to include not just those who can’t provide for their own food, clothing and shelter, but also those who don’t seek needed medical treatment. It failed, in part because opponents considered it ineffective and dangerously expansive.

More than 5,000 people in the state were on permanent conservatorships, and close to 2,000 were on temporary conservatorships, as of 2016-2017, according to data collected by the Department of Health Care Services. The data is incomplete; Scarlet Hughes, executive director of the California State Association of Public Administrators, Public Guardians and Public Conservators, calls it “extremely inaccurate.” 

Last year lawmakers agreed to create a narrow 5-year pilot program that makes it easier for three counties (San Francisco, Los Angeles and San Diego) to conserve homeless individuals with serious mental illnesses or substance-abuse disorders. The program allows courts to conserve individuals who have been placed under a 72-hour psychiatric hold at least eight times in a year. A second law, passed this year, expanded the rules to allow 50 to 100 more people in San Francisco to be placed under conservatorship.

Civil-rights advocates have raised serious concerns: In 2018, Susan Mizner, the disability rights program director for the ACLU, described conservatorship as “the biggest deprivation of civil rights aside from the death penalty” and said the law would incentivize police to repeatedly detain homeless individuals.

So far, only San Francisco has adopted it. That reflects another reality: Different counties have different rules. Even without the pilot program, depending on where you live, public defenders, judges, public guardians and others have different interpretations of the law.

“It varies from county to county, it varies within counties,” said Randall Hagar, government relations director for the California Psychiatric Association. “What is ‘gravely disabled’ here may not be considered ‘gravely disabled’ there.”

Because counties must use local funds to pay high placement costs—and because not all counties have the same types of services available—variations are a significant concern.

Disability rights advocates insist that maintaining the standards outlined by Lanterman-Petris-Short is essential to protect people’s civil rights. Most people with serious mental illnesses aren’t refusing help, they say; appropriate help just isn’t available.

Lynn Rivas, associate director of Oakland-based Peers Envisioning and Engaging in Recovery Services, understands that families feel desperate. She knew a woman with paranoid schizophrenia who lived on the streets of Richmond. Mental-health workers tried repeatedly, but couldn’t get her to come inside.

Even though “it breaks my heart,” Rivas said, she’s willing to live with that consequence. “I think involuntary imprisonment is worse,” she said.

Heather, a program coordinator at the organization, has herself experienced involuntary treatment. In the hospital, she said, everything was taken from her, and her entire schedule revolved around medication.

“I think it’s just really cold the way they treat you,” she said. “It’s like you have a disease. … They treat you like you’re not a human being.”

Once she stabilized, she said, the hospital discharged her back to the streets, without addressing her underlying issues. The experience not only didn’t help her, she said; it made her afraid to seek help.

Some worry that public dismay about the current homelessness crisis will encourage lawmakers to strip people of their rights.

“It’s still political failures that are trying to be masked with solutions that may decrease the visibility of individuals on the street,” said Curtis Child, director of legislation at Disability Rights California. He also compares the situation of people with mental illness to that of people with developmental disabilities. For the latter group, deinstitutionalization was accompanied by the creation of regional centers, he said, “in which everyone gets a plan, everyone gets a worker.

“With mental illness, we did nothing.”

For Child, and many other advocates, the solution is not more conservatorship; it’s creating affordable housing and more robust mental health services.

“The volume of individuals who are entering homelessness on a given day is overwhelming all of our systems,” said Michelle Cabrera, executive director of the County Behavioral Health Directors Association of California. “We’ve got a serious problem on our hands.”

Dr. Amy Barnhorst, vice chair of community and hospital services for the UC Davis Department of Psychiatry, agrees that the focus should be on building out the mental-health system, not changing the law.

“It’s like cutting more doors into an empty building,” she said. “There’s not the services there. We don’t have the workforce. We don’t have the treatments. We don’t have the infrastructure.”

Even if a change in law permitted more people to be conserved, a shortage of placements and “a gross lack of funding” for county programs means there would be nowhere to send many of them, said Hughes, of the California State Association of Public Administrators, Public Guardians and Public Conservators. Earlier this year, a state budget proposal to increase the amount of funding for public guardians by 35 percent—or $68 million—failed.

County conservators receive no direct state funding, and in the past five years have received a huge influx in clients diverted from the criminal-justice system, Hughes said. Some counties went from five referrals a month to 30 or 40, she said.

“They are drowning,” she said.

Simultaneously, the number of facilities that can take them is shrinking, said Chris Koper, a legislative analyst for the organization. At one point, she said, she and some friends started listing the facilities in that county that had shut down. They stopped when they got to 35, she said: “It was too depressing.”

That leaves many conservatees in a “placement pending” status, stuck in jails or hospitals. In some cases, conservators have resorted to having staff members care for people with mental illness in hotel rooms rather than leave an individual on the streets, she said.

Most state hospital beds are now reserved for people in the criminal-justice system. Inmates with mental illness can wait in limbo for months or even years in county jails before a bed opens up. Five years ago, an average of 343 inmates with mental illness were awaiting placement. Last year, the average was 819.

“The easiest legislative fix is to expand conservatorship,” Koper said. “It then will appear that the Legislature is trying to do something. But as is often the case with social problems, the wound is so much deeper than that. And the wound will require a lot of money.”

As San Francisco has assumed new authority to place people under conservatorships, the San Francisco Chronicle found a backlog. In a locked ward at San Francisco General Hospital, individuals who were conserved were waiting four months for placement in Napa State Hospital, and even longer for a residential facility.

A woman who answered the phone at the public guardian’s office in Solano County, where Rippee lives, said she didn’t have time or permission to talk, repeating several times, “We’re extremely short-staffed.”

Gerald Huber, the county’s director of Health and Social Services, noted that even if Rippee were to be conserved, there are very few facilities in the state that accept people with traumatic brain injuries—and they are always full with waitlists.

Rippee’s sisters are aware.

“If they tell him, ‘Mark, you’re conserved’—” Privatte began.

“—where are they going to put him?” Hanson concluded. “There’s no place.”


The events of June 21, 1987, are seared in the minds of Rippee’s twin sisters:

Rippee had purchased a Harley-Davidson just 10 days earlier, but he was already talking about selling it. With his slight frame, the big bike felt unwieldy.

The family had gathered for a Father’s Day barbecue in Vacaville. Rippee, 24, was optimistic about a budding career in construction. He was popular with girls and never went anywhere without his guitar.

That evening, he took off down a country road toward Hanson’s house. A car swerved into his lane. Trying to avoid it, Rippee steered off the road into a dark field.

A neighbor heard the crash. Officers searched for an hour, following the moans, before discovering a gruesome scene: Rippee had smashed into an antique grain harvester. The impact had ripped his eyes from their sockets, knocked out his teeth, split his head open and strewn brain matter on the ground. Paramedics told the family they were so sure he was dead that they initially didn’t turn on the siren.

His sisters rushed to the hospital, where a team of surgeons was attempting to piece their brother’s brain and body back together. Their father was overwhelmed, Hanson said, and asked her to take over medical decision-making.

After Rippee stabilized, a neurosurgeon warned the family it would take a few years for him to recover from the brain injury. Then, at some point, his mental health would decline. The doctor recommended Rippee be transported to a state rehabilitation facility where he might need to spend his entire life, his sisters said.

Instead, Hanson said, their father grabbed the papers giving her legal decision-making over her brother’s care and shredded them. His only son, he insisted, was coming home.

“This is how we lost complete control,” she said.

Under his mother’s care, Rippee did heal somewhat, his sisters said. He was completely blind, had severe damage to his frontal lobe and was suicidal. But, for a time, he was able to take computer classes.

Then the delusions crept in, his sisters say. He heard voices in the air conditioner. He tried to jump out of a car on a freeway overpass, nearly pulling Privatte with him. 

Still, for years, Rippee lived with his family. For a while, Privatte housed her brother in a 60-foot trailer adjacent to her house. Neighbor Chris Plowman, at the time a volunteer firefighter, remembers seeing smoke coming from the trailer one morning and hearing Privatte scream, “Save my brother! Save my brother!”

Plowman kicked in the door and ran through the trailer, looking for Rippee. He wasn’t inside. The trailer burned to the ground.

Then Rippee threatened to kill his mother with an ax, according to his sisters, who say the family felt it was no longer safe to have him live with them. But, gradually, he ran out of other options. Local motels refused to rent to him, his sister said.

Karen Newton, an office assistant with Solano County, first met Rippee in front of the county building where she worked; he was sleeping on a strip of cardboard. She bought him taquitos, chocolate milk and clean clothes. Newton, whose own son has schizophrenia and is currently in Napa State Hospital, was disturbed by the frequent assaults she saw against Rippee, including a bad beating that left him swollen.

“The things I’ve seen in the last year have been horrifying,” she said.

In the past 15 years, Vacaville police say they have arrested Rippee 25 times, charging him with unlawful camping and public intoxication.

Sgt. Aaron Dahl, who supervises the community response unit for Vacaville Police, says he wants people like Rippee to stay inside, take medications and get help, but “that’s not the reality of how things work.”

“I wish I had a magic wand that could go help everybody,” he said. “And it’s very hard, because there’s not an easy answer for everybody. There’s just not.”

In early 2018, Privatte said her daughter saw members of a Solano County community Facebook site criticizing their family for abandoning Rippee.

The twins intensified their efforts to help their brother.

“The law has stopped Mark from getting treatment,” Privatte said. “The law. Not us.”

On April 24, 2018, Privatte told the Solano County Board of Supervisors that her brother had attempted suicide more than 20 times, and that other people beat and robbed him regularly.

“It’s not because I want to lock my brother up and be done with him,” she said, crying. “It’s because I want him to be safe.”

“What can we do to help?” asked Supervisor Skip Thomson. “Because what we’re doing is unacceptable.”

Privatte showed up repeatedly to beg the board for help. Last spring, she received an email from Thomson’s office on behalf of the county, explaining that her brother could not be conserved, in part because each time he was placed on an involuntary hold, he stabilized to the point that he legally had to be released.

“This is not a situation that we have ignored nor that we condone,” the letter said. “Simply the law requires stringent standards to impose conservatorships—standards that so far we cannot meet.”

Huber, the director of Health and Social Services, said that “many, many, many different agencies” have interacted with Rippee over the years, and the county has made—and continues to make—efforts to provide treatment. 

“I’ve struggled with this for the five years I’ve been here,” he said. “The street is not an appropriate place for him to live.”

The county this year implemented Laura’s Law, a 2002 state law which allows for court-ordered outpatient treatment. A few weeks ago, Rippee’s mother applied for it on her son’s behalf. But the program doesn’t serve someone with a traumatic brain injury, Huber said.


On Sept. 27, someone posted a picture of Rippee on the Facebook group. His head looked swollen; his sisters recognized symptoms of a brain abscess.

Privatte convinced her brother to go with her to the hospital, where he had surgery the next morning. After two weeks, the hospital transferred him to a Suisun City board-and-care. In late October, he returned to the streets.

That same week, dozens of mental-health leaders from around the state gathered in Sacramento to talk about the future of Lanterman-Petris-Short. They discussed how counties lack the resources to build out a continuum of care.

Sacramento Mayor Darrell Steinberg asked his colleagues if the debate around involuntary treatment might be reframed to insist that people have both a right—and an obligation—to come indoors. That would mean that, before the state could compel people to come indoors, they would have to have safe, appropriate placements to offer them.

“Our North Star needs to be to end this horrific situation,” he said.

A few weeks later, I found Rippee at a Vallejo strip mall, asleep on a patch of concrete littered with dirty socks and desiccated orange peels. His head rested on a blue IKEA bag, which held a pale green fleece blanket studded with burrs.

After Rippee woke up, he requested a coffee the way he likes it—a lot of sugar, a little coffee. He was friendly and talkative, his facts smoothly interwoven with delusions. He talked about the beauty of classical music. He recalled delivering pies for his parents’ business. Then he toggled to concerns about the KKK chasing him: “I’m trying to stay ahead of those guys,” he said.

Ultimately, Rippee said, he wants home with a shower and someone to care for him. He doesn’t want to be in a locked facility, but he does wish he could live inside.

“At night, it gets cold,” he said. “I just sit there and shake.

“To leave a blind man outside, you know, I just figured the county could do better than that,” he continued. “They’re not supposed to leave me outside. The United States of America is nice enough. They’re not supposed to let this happen.”

CalMatters.org is a nonprofit, nonpartisan media venture explaining California policies and politics.

Published in Local Issues

State Sen. Jim Beall is angry.

Four times now, he has introduced legislation to better enforce state and federal “parity” laws, which require equal treatment of mental and physical health problems. Four times, that legislation has failed.

As he enters his final year in the Legislature, the San Jose Democrat plans what he calls a “full-frontal assault.”

“I’m going to put even more effort into next year,” Beall said, “because I’m madder than hell about it.”

California’s parity mandate was signed into law in 1999, and a federal parity law followed in 2008. But the state has struggled to ensure those laws work‚ which helps explain why parity feels like an empty promise to so many Californians. More than half of Californians believe that most people with mental health conditions can’t get the services they need, according to a poll conducted last year by the Kaiser Family Foundation and the California Health Care Foundation.

Those who do get services often have to search hard and pay extra for them: California patients were more than five times likelier to have office visits for mental health or addiction problems from providers outside of their insurance plan’s network than patients seeking medical or surgical care, according to a new analysis by healthcare consultants Milliman Inc. Insurers here paid primary-care providers 15 percent more than they paid behavioral-health providers.

“We need stricter enforcement of mental health parity laws,” Gov. Gavin Newsom declared during his campaign. That didn’t happen again this year, although Dr. Tom Insel, Newsom’s top mental-health adviser, recently told CalMatters the administration intends to take “a fresh look at parity enforcement.”

“Instead of doing this topic by topic, let’s step back and find an overall plan, a blueprint, that tells us: What’s the system we want?” Insel said. “I don’t think the state’s done that for a long, long time.”

What state officials have been doing is rebuffing many attempts to tighten parity enforcement. The most recent failure: Beall’s 2019 bill to ramp up requirements for health plans to report parity-compliance data to state agencies each year instead of every three years, as it does now. The bill would have required the agencies to report results to the Legislature, and to post them on their websites to make them easily accessible to the public. Beall says that would help make the state less reliant on patient complaints to trigger enforcement. The bill also would have prohibited insurers from requiring prior authorization and “step therapy”—or making patients first try lower-cost medications before receiving other prescriptions to treat substance abuse.

With a public desperate for better mental health services, what is keeping the state from ensuring that health insurers and plans comply with state and federal parity laws?

Some note the lack of the kind of broad, emotionally affecting campaign that has moved the needle in other states. There’s also disagreement among mental-health advocates about whether Beall’s proposals would best address the problem.

The senator, for his part, has another explanation.

 “The insurance companies have too much power in Sacramento on the subject of mental health,” he said. “Whatever support I’ve gained has been countered by them effectively. … They’re the best lobbyists in Sacramento that money can buy.”


Industry representatives maintain that a crackdown is unnecessary, saying the real challenges relate not to compliance, but to a well-documented statewide shortage of mental-health providers.

“Health plans in California have made mental health a top priority, going above and beyond what the mental-health laws are requiring,” said Mary Ellen Grant, spokeswoman for the California Association of Health Plans. Many plans are putting behavioral health providers in primary care offices and using more telemedicine, she said. “We’re not aware of any legislation that would improve whatever it is that Sen. Beall thinks is the issue.”

Leanne Gassaway, a senior vice president for America’s Health Insurance Plans, warned “there will be 50 different flavors of auditing and reporting” if each state creates its own parity reporting tool. Instead, she recommended the federal government create a single one.

“We don’t have a problem with reporting,” she said.

States aren’t asking the right questions or getting granular enough data, said Dr. Henry Harbin, former CEO of the managed behavioral health care company Magellan Health. The result: California’s approach “has not produced the change you would expect it to have.”

Once a problem is identified, is the state doing enough to enforce it? 

Beall doesn’t think so, and neither does Meiram Bendat, a Los Angeles attorney and psychotherapist who won a much-touted case this spring. In that case, a Northern California federal court found that United Behavioral Health had wrongly restricted treatment for patients with mental-health and substance-abuse disorders in order to cut costs.

Bendat said that, over the years, many patients had asked the state Department of Managed Health Care for help with mental-health claims denied by United Behavioral Health. But he said the department, which oversees health plans that receive monthly fees to provide health care for their members, has failed to inform the public of any systemic, corrective action against the insurer.

He uses the terms “toothless and ineffective” to describe the department’s parity enforcement.

California allows plans to decide, for themselves, what makes a treatment “medically necessary” based on clinical standards. Critics, such as Bendat, contend plans often apply the wrong standard of care. Some other states require the use of medical necessity criteria determined by nonprofit, clinical specialty organizations.

“California is behind the curve in this regard,” Bendat said. “The abuses that we see by managed care are widespread and ruinous, and they need to be stopped,” he said.

Bendat and others do praise the work of the Department of Insurance, which covers a small fraction of the state’s health plans.

The Department of Managed Health Care said in an email that it “works diligently to ensure that health plans comply with state and federal requirements regarding mental health services.”

This includes surveying all licensed plans every three years, interviewing plan staff, reviewing enrollee files, and tracking complaints. In recent years, the department added two staff members and conducted focused comprehensive reviews of 25 health plans’ methodologies for providing mental health services. It then required those plans to eliminate impermissible day and visit limits, revise prior authorization requirements, and reimburse enrollees a total of more than $517,000. In the last decade, it has cited health plans dozens of times for mental health-related violations, resulting in more than $4 million dollars in fines—most levied against Kaiser in 2013.

The department says if patients feel they have been denied medically necessary treatment by their health plans, they can appeal to the state for an independent medical review. But critics say the vast majority of patients never appeal.


Sen. Beall is outraged by the swelling numbers of untreated individuals residing under doorways and overpasses.

“It sounds horrible, doesn’t it?” he said. “That’s because that’s what it is. It’s a horror.”

Beall was an undergrad studying urban planning and political science at San Jose State in the early 1970s when Gov. Ronald Reagan began shuttering the state’s mental hospitals at the same time traumatized veterans returned from Vietnam.

Years later, as a Santa Clara County Supervisor and liaison to the county mental-health commission, Beall learned how mental health and substance abuse impacted all corners of society: housing, criminal justice, health, education and foster care.

“We kept seeing people ending up in our system because private insurance wouldn’t cover them adequately,” he said.

After Beall was elected to the Legislature in 2006, he began trying to pass laws to strengthen mental health parity. One made it through the Assembly and died in the Senate. Another made it through the Senate and died in the Assembly. A third, which would have allowed additional penalties of $2,500 per patient per day for each parity violation, was vetoed by Gov. Jerry Brown, who said the state insurance commissioner already had “broad authority” on enforcement. The most recent bill never left the Senate.

 “I’m in a lot of pain right now. It hurts,” Beall said at a Sacramento forum on mental health organized by CalMatters a few days after the latest bill died. He has spoken publicly in the past about having a family member with schizoaffective disorder. “I tried four times, and it’s actually getting harder to get it passed. … My own colleagues killed it.”

The industry has opposed parity laws for a long time. Health insurers “fought tooth and nail” against California’s state parity law, stopping it twice in the 1990s before it ultimately became law, said the law’s sponsor, former state Assemblywoman Helen Thomson of Davis. A psychiatric nurse-turned-legislator, she said the law was eventually pared back to cover just nine serious mental illnesses because of this pushback.

In the case of Beall’s most recent bill, he says he had to remove the parity provisions, because staff and members of the Senate Health Committee didn’t agree with them. But he also insists that some of his colleagues are too connected to health insurers, allowing former staff members and legislators who work for the industry to use these relationships to stop his bills.

In the years that Beall has been trying to pass parity legislation, health insurers have contributed almost $10 million directly to winning candidates and industry lobbyists have spent more than $85 million.

Other states did pass parity-related bills last year, among them Colorado, Connecticut, Delaware, Illinois, New Jersey and Tennessee. A massive publicity effort featuring compelling personal stories, combined with negotiations, may be part of the equation—and part of what’s been missing in California. Health insurers have often dropped their opposition after intensive negotiations and media and education campaigns, said Tim Clement, director of legislative development at the American Psychiatric Association.

Clement, who was at the negotiating table in many of those states, but not California, called it “pretty close to impossible to get a bill passed if insurance industry-opposed.” He blamed California’s inaction partly on the lack of “a cohesive, boots-on-the-ground movement” for parity.

In Colorado—which just passed an expansive parity bill that will close loopholes, improve transparency and enforcement, and strengthen mental health prevention and screening—“we just were relentless,” said Lauren Snyder, state policy director with the advocacy organization Mental Health Colorado. That included working with media outlets to share personal stories of individuals harmed by lack of mental health care, and ads urging people to contact their legislators.

Such a movement was part of what eventually worked in California in the 1990s, said former Assemblywoman Thomson. She said she had a full-time public-relations person working on the effort to pass a parity law; that major newspapers in the state editorialized in its favor; and that many legislators gave personal testimonies about how a lack of mental health care had impacted their loved ones.

That law now has strong provisions for the coverage of medically necessary treatments for serious mental illnesses like schizophrenia and bipolar disorder, but does not cover a wide range of other mental-health conditions or substance-abuse disorders. Some parity advocates say California needs to ensure medically necessary treatment for more individuals, including those with substance-abuse disorders. 

Dr. Richard Pan, a Sacramento pediatrician who chairs the Senate Health Committee, wants to give plans more incentives to serve people with serious mental illnesses.

“No one wants to be known as the health plan with the best mental-health coverage or diabetes or asthma,” he said. His idea: a shared risk pool to reward plans that provide quality care for people with chronic conditions.


For a long time, Sen. Beall has “carried the mantle on (mental health parity), kind of alone,” said Sacramento Mayor Darrell Steinberg, a former state Senate leader who founded the Steinberg Institute to advocate for mental health policies.

Beall calls his inability to pass parity legislation thus far “my biggest failure as a legislator.”

Earlier this year, the Assembly passed a resolution calling on all relevant state agencies and the Attorney General to ensure that all health insurers are complying with federal and state parity laws. But a resolution, while it may raise awareness, is akin to a suggestion.

Beall says he’d like to introduce one more parity bill before he terms out—though he’s still working out the details.

“My style is to keep fighting and fighting and fighting,” he said with a laugh. “I don’t give up.”

Jocelyn Wiener is a CalMatters contributing writer. Her reporting is made possible by a grant from the California Health Care Foundation. CalMatters.org is a nonprofit, nonpartisan media venture explaining California policies and politics.

Published in Local Issues

California’s public schools have enjoyed a remarkable restoration of funding since the bone-deep cuts they endured during the recession—but many are now facing a grave financial threat as they struggle to protect pensions crucial for teachers’ retirement.

Over the next three years, schools may need to use well more than half of all the new money they’re projected to receive to cover their growing pension obligations, leaving little extra for classrooms, state Department of Finance and Legislative Analyst’s Office estimates show. This is true even though the California State Teachers’ Retirement System just beat its investment goals for the second straight year.

Some districts are predicting deficits, and many districts are bracing for what’s to come by cutting programs, reducing staff or drawing down their reserves—even though per-pupil funding is at its highest level in three decades, and voters recently extended a tax hike on the rich to help pay for schools.

At the same time, some districts are grappling with how to simultaneously afford raises for teachers who have threatened to strike. The situation could become even bleaker if California’s economy doesn’t keep growing.

If there’s another recession—which economists say is increasingly likely, given the record length of the expansion under way now—the higher pension payments scheduled could push some districts deeper into the red, Legislative Analyst’s Office data indicates.

“Many districts’ budgets would be upside down with expenses growing faster than revenues,” said Michael Fine, CEO of the Fiscal Crisis and Management Assistance Team, the state agency responsible for overseeing schools with financial problems.

School systems that saved money over the last few years will be able to use it to buy time, Fine said, but those reserves “won’t eliminate the impact or make that problem go away.” Tackling it will likely require new sources of revenue or an array of cuts.

“Building maintenance could suffer; grounds care could suffer; class size could suffer; instructional coaches could suffer; athletic programs could suffer; technology could suffer; intervention programs could suffer,” Fine said.

The problems stem from the state Legislature’s reticence to mandate steeper payments into the California State Teachers’ Retirement System. The system was badly underfunded and careening toward collapse four years ago when school districts, teachers and the state all agreed to pay more to reduce its unfunded liability, which now stands at $107 billion

Districts took on the greatest share of those new costs, agreeing to increase payments from 8 percent of their payroll in 2013 to 19 percent by 2020.

No matter how burdensome the larger and larger pension payments may be, actuaries say they’re necessary to protect teachers’ hard-earned retirement and prevent the system from running out of money. Teachers don’t get Social Security, and unlike firefighters or police officers, most retirees earn modest pensions of about $55,000 a year.

The Brown administration has directed an additional $20 billion to the state’s public schools since 2013 and says districts have had plenty of time to plan for the pension payments ahead. But many school leaders and advocates want the state to invest even more, especially since California still ranks near the bottom in per-pupil spending compared to other states.

“Knowing that these liabilities were growing, we provided districts with the resources they needed to plan accordingly,” said H.D. Palmer, a spokesman for the state Department of Finance.

Meanwhile, the state’s largest teachers union is downplaying the problem and encouraging its members to bargain for raises. California’s teachers may be among the nation’s most generously paid, but they say the money doesn’t go very far, because the state’s cost of living is so high.

School officials are left with a Gordian knot of politically charged problems, forced to make escalating payments into the pension fund while trying to elevate disadvantaged students’ sagging classroom performance, which remains among the country’s worst despite the state’s big investment in their learning through a policy championed by Brown.

“We need to graduate more kids and close academic achievement gaps, but we can’t move the needle when costs are rising like this,” said Dennis Meyers, executive director of the California School Boards Association, who stressed that his group is not seeking to reduce teachers’ retirement benefits.

“We simply need more revenue, and we’re out here waving the white flag, looking for relief.”

Each of California’s school districts is bound to tackle these challenges differently, so CALmatters visited three of them whose circumstances are emblematic of what others across the state are experiencing. During those visits, we spoke with the people working to solve the problem.

Fremont Unified devotes a greater share of its budget to salary than any other district in the state—69 percent. (The three Coachella Valley school districts devote either 55 or 56 percent. See the percentage devoted to salaries at each of California’s school districts here.) So when the largest pension payments are phased in, Fremont will be hit especially hard. That means the district’s budget could face cuts even as enrollment in the Bay Area school system grows.

Sacramento City Unified knew that larger pension payments were coming and saved money to prepare for them. Then the local teachers union criticized the district for hoarding cash and threatened to strike. Now the contested funds are being used to finance a raise that teachers say is long overdue—and that the county superintendent believes the district can’t afford.

In Los Angeles, growing demand for charter schools and a dwindling birth rate has led to declining enrollment in the district’s own schools, which means pension payments will rise even as the district’s state funding shrinks. School officials recently predicted that a quarter-billion-dollar budget deficit was just two years away.


Raul Parungao’s distinctive grin and his cheery demeanor belie his concern about Fremont Unified’s finances.

Situated between Oakland and San Jose in the pricey Bay Area, the school system pays its employees more than most. That makes it a desirable place to work, but also means it will be hit especially hard when the largest payments required under Brown’s pension plan are phased in.

“There’s this sense in the community that we’re flush with cash, but I try to remind people about the other half of the story,” said Parungao, the district’s chief business officer.

Even though revenue is rising because enrollment is growing, the district must hire and pay more employees to serve them. And over the next three years, while Fremont predicts its revenue will grow by $26 million, a 7 percent bump, it also expects its employee pension and health care costs to climb by $14 million, a 23 percent surge.

“Here’s the bottom line: the extra revenue we expect to get from the state won’t be enough to keep pace with our pension contributions,” Parungao said. “The problem hasn’t exploded big yet, but it will. It’s only a matter of time. I haven’t met another chief business official who isn’t concerned about this.”

Meanwhile, Fremont’s teachers just won a small raise after months of protracted negotiations.

The current pay scale is competitive, with veterans making $114,000 a year, but leaders of the local union say about half of the teachers still don’t make enough to live in the district and must commute from up to an hour away.

But no matter how tough it may be for the district to afford this 1 percent pay hike, teachers deserve one, said Victoria Birbeck, the union’s president

“The series of small raises we’ve received haven’t covered cost of living,” she said. “Besides, the district has known about the governor’s plan for a few years now. There should have been better planning.”

Parungao said planning isn’t the problem. The district stretched to offer teachers a raise last year and even had to shift its budget by millions of dollars to accommodate that 2 percent increase, which came after a 13 percent bump over the prior three years. Plans to upgrade students’ textbooks and computers were postponed, and class size for kindergarten, first- and second-grade students increased slightly.

Given the district’s rising pension and other fixed costs, the new agreement’s $7 million price tag will be tough to accommodate. Still, Michele Berke, one of the district’s board members, acknowledged that for many teachers, $1 spent on pensions isn’t as good as $1 spent on salary.

“As we negotiate with the union, STRS is the elephant in the room,” she said in an interview before the deal was finalized, referring to the acronym for the California State Teachers’ Retirement System. “We’re paying toward your future, but those payments don’t help put food on the dinner table.”

Sacramento Mayor Darrell Steinberg only worked with a few key players one weekend last fall when he helped broker a deal to avert a citywide teacher strike, and former school board president Jay Hansen was one of them.

Hansen had tried for months to negotiate the terms of a pay increase for the city’s 3,000 teachers, but the district and leaders of the local teachers union were far apart, and neither side would budge. An acrimonious relationship between the two camps was partly to blame for the impasse.

“It’s like the Hatfields and the McCoys,” Hansen said. “No one remembers why they can’t get along.”

At issue during the talks was the $81 million sitting in Sacramento City Unified’s savings account, a sum the district had built up over several years with spoils from California’s booming economy.

The union said the money should go toward class-size reduction and raises for teachers that would make the district a more attractive place to work. Sacramento educators are paid less than their peers in nearby districts, but they also receive more generous lifetime health benefits, records show. The district said it had saved the money to help cover rising pension and employee health care costs in the lean budget years ahead.

In the end, Steinberg helped craft an agreement that gives Sacramento teachers an 11 percent raise over three years. But just a few weeks after Steinberg announced the deal during a celebratory news conference on the steps of City Hall, Sacramento County Superintendent Dave Gordon delivered some bad news: The district can’t afford it.

“Based on the review of the public disclosure and the multi-year projections provided by the district, our office has concerns over the district’s ability to afford this compensation package and maintain ongoing fiscal solvency,” Gordon wrote in a December letter to the district.

The district’s own budget offers proof of Gordon’s concerns.

Over the next three years, the school system anticipates its revenue will grow by $6 million, a 1 percent increase, while its pension and health care costs grow by more than $18 million, an 11 percent increase. A popular summer program for struggling students has already been eliminated to save money

A second letter Gordon sent in January further underscores his concerns. He called the district’s plan to use one-time money to help cover the cost of the new contract a “poor business practice” that “only perpetuates the district’s ongoing structural deficit.”

“The pension contributions are putting a strain on everyone’s budgets,” Gordon said in an interview.

Even though Hansen had been the union’s adversary during months of stalled contract talks, he defended the district’s decision to offer teachers a raise, calling it “the right thing to do” despite the school system’s escalating pension and health care costs. “We did it anyway,” he added.

Steinberg echoed Hansen’s perspective.

“A strike would have been calamitous for everybody,” he said. And Sacramento isn’t the only place in California where teachers are thinking about a show of force: At least half a dozen other local unions fighting for higher wages have held labor actions in recent months.

In an interview with CALmatters that union leaders cut short after refusing to answer some questions, Executive Director John Borsos rejected any suggestion that the district won’t be able to afford the contract it recently signed or that it ever claimed to have needed the money stockpiled in its savings account to cover rising pension costs.

“They have more than enough to cover the pension increases,” Borsos said. “And they didn’t make that argument at the bargaining table.”


Gov. Jerry Brown promised his 2014 funding plan would shore up California’s teacher-pension system, but at least one young Los Angeles teacher, Josh Brown, says he’s not counting on it. The Oliver Wendell Holmes Middle School special educator is so worried about the system’s solvency that he has an alternative retirement plan: using a portion of his salary to invest in the stock market.

“I’m a fifth-year teacher. I’m 30 years old, and I’m paying into a pension system that may or may not be around when I retire,” he said. “If I were 65 years old and retiring soon, I would feel differently. Right now, I feel frustrated and worried.”

The largest payments required under the plan will be tough for many districts to manage, but they’re going to be especially vexing for large urban districts like Los Angeles Unified, which lost 100,000 students in the last decade and expects to shed more. (Here's the toll of that under-enrollment, school by school.) That’s a problem, because California’s schools are funded on a per-pupil basis, and fewer students means less money.

In Los Angeles, the swift enrollment decline is due to a dwindling birthrate and growing demand for charter schools, which are publicly funded but independently run, meaning their budgets are separate from that of the district.

Over the next three years, the district anticipates its employee pension and health-care costs will climb $90 million, a 5 percent increase, while its revenue dips about $270 million, a 4 percent decline. The result is a $258 million budget deficit in 2020 that the district can no longer paper over, push off or ignore.

“We’re going to have to tighten our belts to save our schools,” said Nick Melvoin, a board member whose stark views on district finances have been criticized by skeptical local union leaders and fellow board members. “We’re in a death spiral.”

The district plans to tackle the deficit with a one-time $105 million bailout from the state and central-office staff reductions. But observers says officials will soon need to consider some painful measures it has so far been able to avoid, like boosting high school class sizes or closing schools with dwindling numbers of students.

At least 55 schools across the district are under-enrolled by a quarter, and 10 of those are half-empty, a CALmatters analysis of building capacity and enrollment data shows.

“Our costs are rising, and as a result, there are hard choices and trade-offs to make each time we look at the budget,” said Scott Price, the district’s chief financial officer.

Parent Paul Robak fears that if the district doesn’t tackle its budget problems soon, it could be taken over by the state. At a recent board meeting, he urged the members to reject a health-care spending plan that would further squeeze the budget. The members listened and thanked him for testifying before approving the agreement.

“It’s as if the board members are prancing down the lane and covering their ears, pretending nothing’s wrong,” said Robak, who has been active on the district’s parent councils for a decade. “Everyone will lose if we fail to act.”

Board member Kelly Gonez also acknowledged the district’s budget woes and the pressure of rising pension and health care costs, but said officials should be trying to ease the pain by finding new sources of revenue, not by making cuts. All but one other board member declined to comment.

Even as a fiscal crisis looms, Los Angeles teachers are negotiating for a raise.

“Everyone who works in the district comes to work with an expectation they’re going to be treated fairly. They need to be treated fairly,” Austin Beutner, a former investment banker and the district’s new superintendent, told the Los Angeles Times. “How we strike that balance remains to be seen.”

United Teachers Los Angeles President Alex Caputo-Pearl declined CALmatters’ request for an interview. However, at a Pepperdine University event held before the state bailout was announced, he pledged to keep pushing for more money and predicted that the state would come through.

“If we take it off the table,” Caputo-Pearl said, “then we are acknowledging that the public district system is going to go off a fiscal cliff, which (is something) I’m not willing to acknowledge.”


Flooded with calls from anxious school officials, Sen. Anthony Portantino of La Cañada Flintridge and several other Democrats pushed earlier this year for a fix that would boost districts’ funding by $1 billion a year. In the end, Portantino convinced Brown to include about half as much in the state budget he signed a few weeks ago.

He insisted that the money be “flexible,” meaning districts may use it to cover rising pension costs or for anything else. But California’s schools are still underfunded compared to other states, and to better fulfill their responsibility to students and taxpayers, that must change, he said.

“In a few months, we’ll have a new governor with a new set of priorities,” Portantino said. “Is there more to do? Absolutely.”

CalSTRS’ first official report on the impact of districts’ growing pension obligations is due to the Legislature in the middle of next year, when school budgets will likely be squeezed the most.

In the meantime, Fine hopes a recession doesn’t strike soon and that districts can manage their budgets without needing to make cuts or send out pink slips. He was a deputy superintendent in Riverside during the Great Recession and remembers how painful it was to carry out round after round of layoffs.

“We lost one of the best counselors and some very bright teachers. I had to layoff someone who years earlier had taught my young children how to swim,” Fine said. “I remember their faces.”

CALmatters.org is a nonprofit, nonpartisan media venture explaining California policies and politics.

Published in Local Issues