San Francisco proposes nation’s first universal mental health care system

San Francisco residents could soon receive free mental health care and substance use disorder treatment under a proposed universal mental health care system aiming to be the first of its kind in the country.

Hillary Ronen and Matt Haney, elected officials on the city’s Board of Supervisors, will officially introduce their plan during Tuesday’s board meeting. The plan, which is called “Mental Health SF,” would include a 24/7 treatment center for any city resident in need of help, whether that’s counseling for anxiety or emergency care to treat a psychotic episode.

“(Mental Health SF) serves everyone from people who are insured but can’t get an appointment for a month or two … all the way to people that are living on the streets in crisis,” Ronen said.

According to a 2016 survey by the San Francisco Health Improvement Partnership, 23 percent of all San Francisco residents struggle with their emotional health. The issue was especially pronounced among lower-income residents, who were 2.5 times more inclined to report “serious psychological distress” compared to their wealthier counterparts.

As a result, demand for mental health care services in the city is high. But Ronen said many residents, regardless of socioeconomic status, have trouble finding a therapist. The San Francisco Department of Public Health reports about 2,000 beds in its current system, leaving some residents with severe mental illness to live on the streets every day.

Ronen represents Supervisorial District 9. Her constituency skirts Zuckerberg San Francisco General Hospital and Trauma Center, site of the city’s only psychiatric emergency room.

“Every single day in our neighborhood, we see people that are leaving the emergency room. They still have their hospital bracelet on, sometimes their gown, and are clearly in a daze, clearly mentally ill … and have been released right onto the streets to fight for themselves,” Ronen said. “You can’t watch this every single day and not feel that the system is in shambles.”

A national ‘crisis’ of care

San Francisco’s situation reflects a growing crisis of mental health care nationwide.

According to a study published last December by independent nonprofit FAIR Health, use of private insurance to cover mental health and substance use disorder treatment rose 320 percent nationally from 2007 to 2017. Private claims for anxiety, post-traumatic stress disorder, major depressive disorder and bipolar disorder all increased by 65 percent or more, individually.

Another report from the American Psychological Association found that there are just 33.9 licensed psychologists for every 100,000 Americans.

The increased demand has challenged the capacity of the existing system, says Mark McGovern, a professor and researcher of psychiatry and behavioral sciences at Stanford University in California.

“It’s hard for people who need and who want care to get it in a timely fashion,” McGovern said. “There’s lots of delay and waitlists, even for people who have cash or who have good insurance.”

Coverage for behavioral health services expanded with Congress passing two major legislative acts around a decade ago. The Mental Health Parity and Addiction Equity Act of 2008 ensured the same coverage for mental health services as for medical operations. Later, the passing of the Affordable Care Act under President Barack Obama denoted behavioral health as an “essential health benefit,” meaning that coverage was required.

However, despite federal law, financial barriers to care have persisted. A 2018 report by the Substance Abuse and Mental Health Services Administration found that 44.6 percent of adults with prevalence of any mental illness and 52.5 percent of adults with signs of severe mental illness did not receive mental health care services “because they could not afford the cost of care.”

McGovern said the implementation of these laws often varies depending on a patient’s state of residence.

“In some places, it seems that behavioral health benefits are equivalent to general physical benefits,” McGovern said. “In other places, they’re carved out and things are reimbursed at a lower rate.”

“So … is it a crisis?” McGovern said. “I think it could be, and certainly for people who need care that can’t find it.”

Coordinated mental health care

San Francisco currently budgets $370 million a year toward mental health care and substance use disorder treatment, investing in more than 300 different programs.

Ronen said these programs don't communicate enough about the patients they share.

“Nobody talks to each other across the programs,” Ronen said. “Oftentimes, people with severe mental illness or substance use illness might go to one program; it could or could not work for them. And then they’re forcefully taken to another program. But nobody’s connecting across these programs to talk about what’s working, what’s not for this individual.”

To account for this, Ronen and Haney’s proposal is based around the idea of “coordinated care.”

The treatment center will include an office space where social workers and case managers work together to monitor past and present patients, Ronen said. Every patient will receive a personal treatment plan, which will be shared between the city’s different existing programs.

“We’ll also make sure providers across different programs are communicating with one another,” Ronen said. “So, when we learn that one type of intervention doesn’t work for someone, we don’t have to repeat it 500 times.”

The plan also includes an expansion of current services, such as residential treatment programs.

Ronen said the project would be funded mainly by state health care money, but she’s also proposing a tax on the city’s CEOs. The Excessive CEO Salary Tax, as it’s being called, would place a surcharge on businesses whose CEOs earn more than 100 times the same company’s typical worker.

The plan would also receive some funding from an IPO tax proposed by fellow Supervisor Gordon Mar, which would raise the stock-based compensation tax on companies when workers cash in their shares.

Some have criticized the two taxes as unstable forms of funding.

Rufus Jeffris is head of communications for the Bay Area Council, a nonprofit that advocates for policies that benefit a strong local economy. Jeffris cautioned city leaders against relying on sources of revenue for public programs that he said could change yearly.

“The city has definitely directed a lot of funding toward mental health services and should be congratulated for that. But we would like to see — rather than adding new taxes and taking volatile and risky taxes on higher income or IPO and CEO income — looking at other ways the city can partner and collaborate with other cities in the region to improve how these services are delivered,” Jeffris said.

Overwhelmed treatment center

Six of eleven supervisors must back Mental Health SF to advance it. Ordinances must be considered twice by the board and then signed by the mayor. If signed, the proposal would be brought before voters as a ballot measure this November.

Mayor London Breed did not attend last week’s press conference where Ronen and Haney announced the legislation, nor did any members of the city department of health, radio station KQEDreported. Ronen said the mayor has yet to take a position, but her presence at the press conference would have been “very rare.”

Jennifer Esteen, an employee of the department of health who works in psychiatric services, supports the proposal. Before her current job, Esteen worked for five years in the psychiatric emergency room at San Francisco General. In that time, she said the facility rarely had a sufficient number of beds. When that happens, Esteen said, patients in crisis must go to a regular emergency room, which “is not equipped to handle people with psychiatric crises.”

Esteen now works for the transitions division, helping mentally ill patients transition through levels of care.

“My hope is that, if this proposal passes, there will be more people like me doing this work and there will be more resources,” Esteen said.