
4 minute read
‘The country is watching’...
put my mom through a lot.”
Her heart broken, Susan would seek out her son on the streets, bringing supplies to his tent. In 2019, after a particularly cold spell, he begged her to let him come home. She responded with an ultimatum: He could move back home if he agreed to get clean and stay on his meds.
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Susan, a lawyer, is among thousands of parents who support Newsom’s CARE Court initiative. For years, families who have watched in despair as children or siblings lost themselves to untreated mental illness have petitioned lawmakers to make it easier to mandate conservatorship and treatment, and CARE Court is a major stride in that direction.
Eight counties, including Los Angeles, San Francisco, San Diego, and Riverside, have volunteered to launch the program this year. All 58 counties will be required to start programs by the end of 2024.
Newsom calls it a paradigm shift. Pushing the measure to passage meant standing against virulent opposition from civil and disability rights groups that argued people have the right to refuse treatment, and warned of a return to the horrors of forced confinement depicted in “One Flew Over the Cuckoo’s Nest.”
“There’s no compassion in stepping over people on the streets and sidewalks,” Newsom said as he signed the Community Assistance, Recovery & Empowerment, or CARE, Act into law last fall. “They need intervention — sometimes that’s tough.”
Some county leaders have also balked, saying Newsom is sentencing people to a system of care that doesn’t exist. They worry a crush of patient referrals will overwhelm county behavioral health systems. They say they need more money, more time, and funding streams guaranteed year after year.
“There isn’t enough treatment capacity. And we can write a prescription for housing, but the reality under CARE Court is we don’t have what it takes to fill that prescription,” said Michelle Doty Cabrera, executive director of the County Behavioral Health Directors Association of California. “It’s a matter of having the level of funding and housing that is going to help that person be successful.”
Newsom’s response to the pushback has grown heated. He points out that local governments already get billions every year to provide mental health services and that recent state budgets have included funding to expand the system of care.
“I’m exhausted by that — $15.3 billion we’ve provided,” Newsom said at a January news conference, referencing homeless investments over the past two years. The state has provided “unprecedented support,” he said, pounding his fist on the podium. “I want to see unprecedented progress.”
Dr. Tom Insel, who formerly led the National Institute of Mental Health and has served as an adviser to Newsom, credits the governor for bold efforts to direct resources and attention to the nexus of mental illness and homelessness. Research indicates roughly 1 in 20 Americans have a serious mental illness, but for unsheltered homeless people, it’s 1 in 4, Insel said.
He sees CARE Court as a “two-sided mandate,” making counties legally liable for providing services for people whose survival is at risk because of untreated mental illness while putting individuals on notice that they are responsible for accepting that help. Still, he worries the state’s homeless population is so overwhelming in scope, their isolation so entrenched, that it will be difficult to make headway.
“You can have all the clinics and all the medicines and all this good stuff to offer, but if people aren’t engaging with it, it’s not going to help,” Insel said. “And if there’s no relationship and no sense of trust, it’s just really difficult to engage.”
For Daniel Goodman, the return to mental health took both carrot and stick. Looking back, he can see his refusal to take his prescribed medication after being diagnosed with schizophrenia — he felt “freer” without it — set him on a dehumanizing spiral. A primal need for food and shelter led him to ask his mom for help. But without her “hammer” — the ultimatum — he would not have agreed to treatment. And without the medication, he said, no doubt he would be back on the streets, at the mercy of his vicious “witch” and scraping to survive.
“I’ve battled this question [of needing medication] for years,” he said, reaching for his mom’s hand in her sunlit living room. “I accept it now.”
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If California is to make a visible dent in its homeless numbers, affordable housing presents the most daunting challenge. The state lacks the extensive shelter networks common in places with colder climates — an estimated 67% of people living homeless in California are without shelter.
And in recent decades, a mire of zoning restrictions and real estate development practices have transformed the housing market, jacking up rents and home prices and shrinking the options for low-wage workers. For every person moved off the streets, many others stand a paycheck or medical emergency away from losing their housing.
The longer people live on the streets, the more their health deteriorates. Addiction and mental health problems deepen. Chronic diseases advance.
“There’s almost nothing as destructive to health as homelessness, and there’s very little that the health care system can do to make up for it,” said Dr. Margot Kushel, director of UCSF’s Center for Vulnerable Populations at Zuckerberg San Francisco General Hospital. “You just fall apart.”
The arrival of COVID-19 — and fears the virus would carve a deadly swath through shelters and encampments — gave Newsom an unexpected opportunity: open housing units in record time by throwing pandemic emergency funds at the problem and circumventing land-use restrictions and environmental reviews that can drag out approvals.
In 2020 he launched “Project Roomkey,” converting dilapidated hotels and motels into temporary housing for homeless people deemed vulnerable to serious covid infections. That morphed into a program to convert underused structures into permanent housing, and today the retooled Project Homekey has laid the groundwork for more than 12,500 housing units.
But much of that is one-time funding for start-up costs. If cities and counties want to participate, they are required to put up money for ongoing operations and services. And many have decided it costs too much to buy in.
“I really wanted to pursue a project, but it just doesn’t work for a lot of rural counties,” said Jaron Brandon, a supervisor in Tuolumne County, a forested province in the Sierra Nevada.
“Rural areas like ours have much lower tax revenues, and we had to figure out five years of funding, so when you start adding up all these costs and requirements, all of a sudden, we can’t afford to think big. It starts cutting into critical issues and basic services like funding roads and wildfire response and public safety.”