Position Category: MHAC

May 7, 2025

The Honorable Scott Wiener, Chair
Senate Budget Committee
1020 N Street, Room 502
Sacramento, CA 95814

The Honorable Jesse Gabriel, Chair
Assembly Budget Committee
1021 O Street, Suite 8230
Sacramento, CA 95814

The Honorable Laura Richardson, Chair
Senate Budget Subcommittee No. 5
1020 N Street, Room 502
Sacramento, CA 95814

The Honorable James Ramos, Chair
Assembly Budget Subcommittee No. 6
1021 O Street, Suite 8230
Sacramento, CA 95814

Re: Proposition 36 Behavioral Health Treatment Implementation Recommendations

Dear Chairs Wiener, Gabriel, Richardson and Ramos:

The below signed coalition of advocates representing behavioral health treatment providers and advocates for safe and healthy communities, respectfully request the Legislature provide funding to expand the capacity to deliver more behavioral health treatment, including for individuals charged with treatment-mandated felony offenses created by Proposition 36. As organizations dedicated to improving behavioral health outcomes across the state, we recognize the urgent need to provide individuals charged with treatment-mandated felonies and those voluntarily seeking treatment and supportive services that often serve as pathways to treatment the comprehensive and accessible treatment and support they need and deserve.

In November, voters sent a clear message that treatment must be part of a successful public safety strategy. Ensuring the availability of appropriate, on-demand behavioral health services for anyone seeking them is essential to meeting needs created by Proposition 36 and reducing entry into the criminal legal system. To do so, we recommend the Legislature take the following actions:

1. Invest $105 Million in Behavioral Health Treatment for Proposition 36: California’s behavioral health treatment system, particularly for substance use disorders, remains under-resourced and oversubscribed. Without additional funding, many individuals eligible for treatment under Proposition 36 will be unable to access the care they need. There is a significant need for substance use disorder treatment capacity across the continuum, particularly acute need for residential treatment capacity given the current wait times can be weeks or even months long.
   
   While it is difficult to estimate the treatment needs under Proposition 36 only a few months into implementation, based on the Judicial Council’s Proposition 36 survey, we anticipate an additional $105 million in treatment investments is needed.1 This investment is critical to ensuring that treatment programs statewide can meet demand, improve outcomes, and provide a path of recovery and opportunity that ultimately create safer communities.
   
2. Build Out the Forensic Behavioral Health Continuum of Care with Focused Workforce and Infrastructure Investments: California faces a devastating behavioral health workforce crisis. Estimates from the Steinberg Institute suggest that we need to add 375,000 workers over the next decade to meet the demand for care. This estimate does not include the increased need for services being driven by Proposition 36. While the state is poised to invest billions into the build-out of new capacity through the Bond BHCIP and Proposition 1 workforce investments, it is important that a portion of these dollars are prioritized for the buildout of a forensic behavioral health continuum of care with a focus on individuals in the criminal legal system who have behavioral health needs.
   
3. Ensure Behavioral Health Clinicians Perform Evaluations and Make Level of Care
   Recommendations: Clinical evaluations and decisions regarding the appropriate level of treatment for individuals should be made by qualified behavioral health clinicians working within the county behavioral health safety net and using the criteria and guidelines set forth in the most recent versions of treatment criteria developed by the nonprofit professional association for the relevant clinical specialty, such as the ASAM criteria for substance use disorders. This will ensure that those mandated to treatment under Proposition 36 receive care that is evidence-based, appropriately tailored to their individual needs, and in compliance with insurance-based medical necessity requirements.
   
4. Direct Treatment Funds to State and Local Behavioral Health Agencies: To maximize the effectiveness and accountability of Proposition 36 funding, all treatment dollars should be allocated to appropriate state and local behavioral health entities, specifically the Department of Health Care Services and county behavioral health departments. These entities have the expertise necessary to deliver high-quality treatment services and oversee program implementation.
   
5. Require Reimbursement by Commercial Insurance: Proposition 36 is payer agnostic and not all those who meet criteria for the treatment-mandated felony will qualify for Medi-Cal County behavioral health services. County behavioral health agencies do not have the infrastructure nor funding to serve additional populations within the county behavioral health delivery system. The Legislature should leverage existing commercial insurance requirements for behavioral health care (SB 855, Wiener, 2020) and further clarify that commercial insurance is required to cover treatment provided under Proposition 36, similar to the language included in the CARE Act (SB 1338, Umberg, 2022), will ensure that county behavioral health agencies and providers are reimbursed for the services provided to individuals who may not meet Medi-Cal eligibility criteria.
   
6. Implement Robust Spending and Outcomes Reporting: To ensure that Proposition 36 achieves its intended goals, all new funds should be accompanied by clear spending and outcomes reporting requirements. Transparency and accountability measures should not duplicate existing reporting, outcomes, and accountability requirements and leverage existing reporting mechanisms to the extent possible in order to reduce the documentation burden on providers and plans. Requiring reporting will help track the success of the various investments made by the state, identify areas for improvement, and demonstrate the positive impact of investing in behavioral health services.

These recommendations can help ensure that individuals charged with treatment-mandated felonies receive the care they need. However, there is also a need to build out our substance use treatment system beyond these recommendations to ensure Californians get care before they are involved in the justice system. We would urge the Legislature to continue to invest in substance use treatment and support services. Our coalition stands ready to collaborate with the Legislature and the Administration to advance these vital improvements. Should you have any questions, please feel free to contact Tara Gamboa-Eastman with the Steinberg Institute at tara@steinberginstitute.org.

Sincerely,

Karen Larsen
Chief Executive Officer
Steinberg Institute

Le Ondra Clark Harvey
Chief Executive Officer
California Behavioral Health Association

Robb Layne
Executive Director
California Association of Alcohol and Drug
Program Executives

Pete Nielsen
President and Chief Executive Officer
California Consortium of Addiction Programs and
Professionals

Michelle Doty Cabrera
Executive Director
County Behavioral Health Directors Association

Heid Strunk
President and CEO
Mental Health America of California

Anne Irwin
Founder and Director
Smart Justice

Anthony Di Martino
Government Affairs Director
Californians for Safety and Justice

Grey Gardiner
State Director, California
Drug Policy Alliance

Claire Simonich
Associate Director
Vera Institute for Justice

Paul Yoder
Legislative Advocate
California State Association of Psychiatrists

Selena Liu Raphael
Senior Policy Advocate
California Alliance of Child and Family Services

Chad Costello
Executive Director
California Association of Social Rehabilitation
Agencies

Tyler Rinde
Director of Government Affairs
California Psychological Association

Meron Agonafer
Policy Director
CalVoices

CC:
Senator Akilah Weber, Senate Subcommittee No. 1 Chair
Assemblymember Dawn Addis, Assembly Subcommittee No. 1 Chair
Scott Ogus, Senate Budget Deputy Staff Director
Nora Brackbill, Senate Budget Subcommittee No. 5 Consultant
Jennifer Kim, Assembly Budget Subcommittee No. 6 Consultant
Patrick Le, Assembly Budget Subcommittee No. 1 Consultant
Eric Dang, Principal Consultant, Office of President Pro Tempore Mike McGuire
Marjorie Swartz, Principal Consultant, Office of President Pro Tempore Mike McGuire
Shaun Naidu, Policy Consultant, Office of Speaker Robert Rivas
Rosielyn Pulmano, Policy Consultant, Office of Speaker Robert Rivas

1 This estimate was determined by estimating the annual number of treatment-mandated felonies to be 13,164 people per year based on the data from the Judicial Council Proposition 36 Survey. This estimate assumes that treatment costs will be $20,000 per person on average and that 80% percent of those charged with treatment mandated felonies will be Medi-Cal eligible and, therefore, 50% of the costs will be covered by the federal government. The formula used was (13,164)*(0.8)*(0.5)*($20,000) = $105,312,000.3

April 25th, 2025

Department of Health Care Services
Behavioral Health Transformation
1501 Capitol Ave
Sacramento, CA 95814

RE: Behavioral Health Services Act County Policy Manual Module 3

To Whom It May Concern,   

Mental Health America of California (MHAC) is a peer-run organization leading the state in behavioral health public policy and advocacy since 1957. The mission of MHAC is to assist and encourage communities, families and individuals to experience hope, wellness and recovery from mental health and substance use disorder issues through voluntary services that are delivered in their local community with compassion and respect for everyone’s dignity and autonomy.   Below are MHAC’s recommendations regarding the proposed Behavioral Health Services Act County Policy Manual Module 3.

Section E.2.1 IP Requirements

Recommendation #1: Add language encouraging meaningful stakeholder engagement in annual updates.

Reasoning: Although the Behavioral Health Services Act (BHSA) does not require a full stakeholder process for annual updates, language in the Act implies ongoing involvement of stakeholders. For instance, Welfare & Institutions Code Section 5892 (e) (1) (A-C) requires counties to include funding for annual planning costs to fund stakeholder participation:

(e) (1) (A) Notwithstanding subdivision (a) of Section 5891, the allocations pursuant to subdivision (a) shall include funding for annual planning costs pursuant to Sections 5963.02 and 5963.03.

(B) The total of these costs shall not exceed 5 percent of the total of annual revenues received for the Local Behavioral Health Services Fund.

(C) The planning costs shall include funds for county mental health and substance use disorder programs to pay for the costs of consumers, family members, and other stakeholders to participate in the planning process.

Additionally, Welfare & Institutions Code Section 5963.03 (a)(2)(A)(i) retains original MHSA language which states:

(2) (A) (i) A county shall demonstrate a partnership with constituents and stakeholders throughout the process that includes meaningful stakeholder involvement on mental health and substance use disorder policy, program planning, and implementation, monitoring, workforce, quality improvement, health equity, evaluation, and budget allocations.

Meaningful stakeholder involvement in processes such as program planning, implementation, quality improvement and evaluation are not one-time processes that can occur once every three years, these are ongoing processes that must be implemented throughout a 3-year period as programs are rolled out and eventually evaluated.

Recommendation #2: Strengthen the language in this section to clearly state that the local agency must “provide an annual report of written explanations to the local governing body and the department for substantive recommendations made by the local behavioral health board that are not included in the final integrated plan or update.”[1]

Reasoning: This is a key section of the BHSA which ensures that Behavioral Health Board (BHB) recommendations are carefully considered. Behavioral Health Board meetings are an open and transparent forum for stakeholder involvement and their impact in the planning process should be maintained.

Section E3.4 Exemption Approval

Recommendation # 3: The manual should state that DHCS will provide counties with specific feedback on why exemption requests are denied.

Reasoning: Exemptions will allow counties to more effectively plan for services that meet local needs. Clarity in how to obtain these exemptions is vital.

Section E4.2 DHCS Review Standards

Recommendation #4: Require BHB review of revised IPs that are found to inadequately address local needs.

Reasoning: The Draft Module 3 states that DHCS may require counties to revise their IP if it fails to address local needs, including prevalence of mental health and substance use disorder and unmet need for mental health and substance use disorder treatment in the county, among others. Revisions to an IP for reasons as substantive as failing to address local needs should be subject to some form of stakeholder review. The input of stakeholders who are intricately involved in the system is vital to ensuring the appropriate use of funds to address local needs and BHB review would provide the opportunity for stakeholder input into revised IPs without unduly burdening the local agency.

E.5.3 Approval Process for Joint Integrated Plans

See recommendation #2

We ask these recommendations be included in the final version of the Behavioral Health Services Act County Policy Manual Module 3. If you have any questions, or if MHAC can provide any assistance regarding the implementation of the Behavioral Health Services Act please do not hesitate to contact me at hstrunk@mhac.org or our Director of Public Policy, Karen Vicari, at kvicari@mhaofca.org. 

In Community,   

Heidi L. Strunk   
President & CEO 

[1] WIC Section 5963.03 (b)