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In early March, Gov. Gavin Newsom unveiled a controversial proposal to compel people with serious mental health issues into care and housing.

Mental health advocates, mayors and family members who stood alongside him at the press conference at a San Jose behavioral health treatment program heralded the plan, known as CARE Court, as a visionary move.

But some county officials say they were stunned.

鈥淭hey really sprung it on everybody,鈥� said Farah McDaid Ting, public affairs director at the California State Association of Counties, who said lawmakers didn鈥檛 consult or even give her organization a heads-up.

Four months later, the bill to establish CARE Court has sailed through all of its policy committees in the Legislature, secured unanimous approval from the Senate in May and is widely expected to become law later this summer. CARE Court 鈥� short for 鈥� has garnered enthusiastic support from leaders of more than 45 cities, many of whom face fiery criticism over their handling of homelessness. Many family members, who for decades have felt stymied by strict eligibility rules for conservatorship, are also celebrating the new plan.

But county representatives continue to ring alarm bells about their ability to implement the proposal, especially as an aggressive timeline comes into focus. A handful of counties have registered support for the proposal, including Marin, Contra Costa and San Diego.

Many of the counties鈥� concerns come in the form of questions: Will the necessary housing be available? Where can they find the outreach workers and therapists needed to serve the population, given massive statewide shortages of both? What happens to all the struggling people who want housing and treatment, and already can鈥檛 get it?

Disability rights advocates are raising fundamental questions about the very premise of CARE Court: Is it effective to compel people into care? Is involuntary treatment a violation of their civil rights?

But many of those who support the concept say the practical questions feel especially pressing right now, as the Legislature continues its deliberations. While many details are still in flux, the gist of the proposal remains the same as initially outlined. Anyone from family members to first responders could petition a civil court to create a court-ordered care plan for people who meet specific criteria. These include a diagnosis of schizophrenia or other psychotic disorders, along with being at risk of harming themselves or others or being unlikely to survive on their own. Participants would receive legal counsel and a range of mental health services, medication and supportive housing. Following a series of check-ins during a yearlong period, the participant could either graduate or be referred to an additional year of treatment. If a person refuses to comply, or 鈥渇ails out鈥�, they could be considered by the court for .

Conversations about CARE Court have been peppered with frequent references to people living on California鈥檚 sidewalks and under freeway overpasses. But the administration hasn鈥檛 been clear about how much of a dent the proposal would make in the state鈥檚 massive homelessness crisis. Prior to the pandemic, more than 161,000 people in the state were estimated to be homeless on any given night; that number has likely grown since. The administration says the program will serve 7,000 to 12,000 people with the most acute mental health needs. Homelessness isn鈥檛 a prerequisite to participate.

The administration says the proposal represents a crucial step toward addressing one of the state鈥檚 great moral and policy failings: the vast ranks of unhoused people languishing with serious mental illness and without care.

鈥淲hat CARE Court is saying is we must create a pathway wherein these individuals that live in the shadows and often die in the shadows, become a priority group,鈥� said Dr. Mark Ghaly, secretary of the California Health and Human Services Agency, who has been championing the program on behalf of the Newsom administration.

CARE Court鈥檚 supporters say no more time can be wasted. Judge Stephen Manley, who started the state鈥檚 first mental health court in Santa Clara County nearly 25 years ago, notes the growing percentage of people in local jails and prisons with serious mental illnesses. Only by mandating that counties prioritize this population, he said, will anything change.

鈥淧eople are always telling me it can鈥檛 be done,鈥� he said. 鈥淭o me it is a tragedy that we repeatedly, year after year after year after year, talk about this issue, do nothing, and all these individuals end up in the criminal justice system.鈥�

Is there enough housing or will there be?

Perhaps the most prominent question that has emerged among legislators and advocates is whether there is enough housing available to get the CARE Court program started.

Short answer: No.

But the state believes that bringing CARE Court participants to the front of the line, along with making unprecedented investments in housing this year, will allow counties to meet the needs of this population. Opponents fear others awaiting voluntary services will be bumped to the back of the line, leaving their needs to intensify.

鈥淚 worry if it houses some but leaves others out, are we just reshuffling things?鈥� said Margot Kushel, director of the Benioff Homelessness and Housing Initiative at Zuckerberg San Francisco General Hospital and Trauma Center.

While the new budget deal includes $65 million this year and $49 million in ongoing annual funding to cover training, court costs and legal representation, counties say the proposal doesn鈥檛 include any new funding for housing or services.

鈥淭here鈥檚 a new door being built onto a small house,鈥� Ting said. 鈥淭here鈥檚 no square footage, there鈥檚 no nothing, just a new door. That鈥檚 what鈥檚 kind of frustrating about the premise.鈥�

The administration points skeptics to a $14 billion multi-year homelessness budget put together before the proposal鈥檚 announcement 鈥� which includes about $5 billion to build thousands of mental health treatment beds and homeless housing. This year鈥檚 budget includes $1.5 billion for interim treatment beds to hold patients over while permanent units come online. In response to counties鈥� concerns that even the bridge beds won鈥檛 be ready in time, the bill鈥檚 authors recently said counties would be phased into the program over two years, starting in July 2023.

Sen. Susan Talamantes Eggman, the bill鈥檚 co-author and a Stockton Democrat, says she believes counties are unhappy with the proposal because it finally holds them to account. It requires that they provide the care and housing a participant needs and if they don鈥檛, face court fines of $1,000 per day. The money, collected by the state treasury, would eventually fund local services for the people CARE Court targets.

鈥淲e鈥檙e not just saying the person has the obligation to accept, we鈥檙e saying the system has the obligation to treat,鈥� Eggman said during a recent hearing.

Counties counter that these penalties will only take away from their already limited resources to treat people.

While the bill says a county has to provide services during the program, courts can鈥檛 enforce a participant鈥檚 post-graduation plans. Advocates worry that without guaranteed housing people will wind up back on the streets, in emergency rooms and county jails.

鈥淲e鈥檙e going to release them back into the streets but we expect them to continue to adhere to the care plan and continue to be taking medication,鈥� said Shonique Williams, a statewide organizer for Dignity and Power Now, who opposes the proposal. 鈥淏ut they鈥檙e going back into survival mode.鈥�

The state doesn鈥檛 keep any sort of waitlist or even a count of treatment beds and housing that鈥檚 available to people exiting homelessness. As a result, it鈥檚 impossible to gauge the exact shortage in each county.

But a state-commissioned report found that more than 80% of counties need more mental health treatment beds and homeless housing. A 2021 study from the RAND Corporation, a nonprofit think tank, 5,000 psychiatric hospital beds and another 3,000 beds at residential treatment facilities and board-and-care homes. The shortage is most pronounced in the San Joaquin Valley and for patients with additional medical needs.

Michelle Doty Cabrera, executive director of the California Behavioral Health Directors Association, said one recent survey showed counties had 14,000 unhoused individuals with serious mental illnesses voluntarily participating in full service partnership programs. But they couldn鈥檛 find housing for more than half of these individuals, in part because many were screened out for reasons related to their mental health conditions, she said.

In Sacramento County, beds are increasingly rare at board-and-care facilities, where residents receive housing, 24-hour care and three daily meals.

鈥淚t is a needle in a haystack right now,鈥� said Terry Fiscus, a behavioral health worker at Turning Point, which contracts with the county.

The less calm and rule-abiding the patient, the less chance they have of getting or keeping a spot, he said. On top of that, facilities have been as housing prices soar and government-set reimbursement rates remain stagnant.

鈥淭here are a lot of people that want to come in all the time. We cannot take them,鈥� said Jeanny Leung, who runs a board-and-care home in Sacramento.

Nina Riggio

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CalMatters

鈥淪queezing blood from a turnip鈥�

Housing isn鈥檛 the only big concern counties are raising. To run, CARE Court requires staff and resources.

Some counties say they fear that, without new funding, the program will end up draining resources from other populations, potentially including children and youth.

Cabrera, of the California Behavioral Health Directors Association, uses phrases like 鈥渟queezing blood from a turnip鈥� and 鈥渞obbing Peter to pay Paul.鈥�

鈥淲e鈥檙e at our limit in terms of what we can do,鈥� she said. 鈥淲e need more resources to do more.鈥�

The proposal鈥檚 proponents argue that there鈥檚 plenty of money to get things up and running. They say county mental health systems have had a huge influx of taxpayer dollars in the past two years, thanks to the Mental Health Services Act, a 1% tax on incomes over a million dollars that was enacted in 2004.

鈥淥ur millionaires in California seem to be doing very well for themselves,鈥� said Karen Larsen, CEO of The Steinberg Institute, a nonprofit focusing on mental health policy, which supports the proposal. She notes that revenues from the tax have hit historic highs 鈥� they were at more than $4 billion this past year.

For two decades prior to assuming her current role, Larsen served as director of Yolo County鈥檚 Health and Human Services Agency. She believes counties can afford the costs of the new program.

鈥淚f they can prove they don鈥檛 have enough resources, I鈥檇 love to see it,鈥� she said.

Phebe Bell, Nevada County鈥檚 behavioral health director, said she was, indeed, able to tap the influx of Mental Health Services Act funding to purchase a new house, providing beds for six people who were unhoused. But strict rules often limit what that pot of money can be used for, she said.

If the county has to pivot to focus on CARE Court mandates, she worries about who won鈥檛 be served.

鈥淢any of our people are only stable because we have someone coming twice a day to deliver their meds and check in with them and make sure their furniture is upright,鈥� she said.

When her county examined their full service partnership program, they found more than a third of the 78 people in their program at any given moment were inadequately housed, with many sleeping on the streets.

鈥淚 don鈥檛 have a single empty bed in our system of care,鈥� she said. 鈥淲ho exactly are we incorrectly prioritizing in our work right now?鈥�

Both sides agree on one specific challenge: a massive shortage of mental health providers.

At the beginning of the pandemic, many counties worried they鈥檇 face significant shortfalls and preemptively laid off mental health workers.

Now, as need surges, staffing has simply not kept pace. Counties are finding themselves losing bidding wars for therapists being courted by everyone from school districts to telehealth start-ups to major providers like Kaiser. Burnout is driving others from the field entirely.

Some counties now face vacancy rates of 30% to 40% in their behavioral health workforce, and many of the nonprofits they contract with are in the same situation, Larsen said.

鈥淚 think it鈥檚 the biggest issue we face in mental health and substance use right now,鈥� she said.

This year鈥檚 budget includes $1.5 billion to build out the state鈥檚 entire healthcare workforce, including hundreds of millions that target behavioral health.

The state鈥檚 public guardians and conservators have also eyed the CARE Court proposal warily. While they are not officially affected by the proposal, they say they expect the program could lead to a surge in new referrals.

The programs are already severely underfunded and understaffed, said Scarlet Hughes, executive director of the California State Association of Public Administrators, Public Guardians, and Public Conservators. Right now, caseloads hover at 65 to 85 individuals per caseworker, though in some counties they鈥檙e as high as 135. That translates into visiting a client every three or four months, she said.

鈥淎ny impact to our members is going to be significant because they鈥檙e underwater already,鈥� she said.

What鈥檚 next?

Questions over implementation, in addition to the ongoing debate over civil liberties, have been woven through CARE Court鈥檚 journey from the start. That hasn鈥檛 stopped the Legislature from voting overwhelmingly in the bill鈥檚 favor. It is expected to easily clear its final hurdles: an appropriations vote later this summer, a floor-wide vote in the Assembly and a signature from the author, the governor himself.

But despite their ongoing questions, counties have conceded that CARE Court is coming whether they like it or not. They know they鈥檙e not likely getting any more money for housing and staffing. For now, they鈥檙e using the appropriations process to to implement the program.

The administration acknowledges that counties around the state face severe shortages. But it remains committed to the idea of a better way to serve the people who are struggling the most.

鈥淐alifornia has done this before,鈥� Ghaly said. 鈥淲e鈥檝e stepped up for the most vulnerable, the most overlooked many, many times. And we can do it again.鈥�

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