California needs public health responses to behavioral health needs

From San Francisco to Los Angeles, there is a crisis on California streets. Our state’s failure to adequately treat and house people with behavioral health needs has led to surges of overdose deaths, overflowing tents on our streets, and concerns about public safety. We believe our government can do better to promote public safety by prioritizing resources on expanding treatment and housing. 

As we emerge from the pandemic, now is the time for change. And we have cause to hope. Voters in San Francisco and Los Angeles have supported increasing funds for housing the homeless. Both counties have shut down jails and diverted resources to treatment. Assembly Bill 369 and Senate Bill 679, both making their way through the legislative process, would expand Medi-Cal access to people experiencing homelessness and provide state support to create affordable housing in Los Angeles. We still have far to go, however. 

Crime prevention requires adequate investments in treatment and housing. Yet, rather than treating those struggling with behavioral health issues, our government has focused almost exclusively on punishing people with untreated needs. We spend billions of dollars on jails and prisons but lack sufficient treatment beds.

In San Francisco, of 18,000 unhoused people, approximately 4,000 have a co-occuring mental illness or substance use disorder — frequently leading them to local hospitals. Yet of those discharged from San Francisco General Hospital’s psychiatric emergency services during the 2017 fiscal year, 40% were not connected to needed services upon release, putting vulnerable people at risk of rapid decompensation. A city audit of that year identified a severe lack of case managers, inadequate hours for people to receive emergency services, and insufficient outpatient options. One statistic is especially telling: In 2019, San Francisco had only 394 mental health and substance use treatment beds. The city’s announcement last week of 400 additional new treatment beds in the coming years was therefore welcome news, but with 10 times more people in need of such treatment beds, this is only a small step. 

In Los Angeles County, there were over 66,000 homeless people as of January 2020. Of those, almost a quarter are mentally ill. The Los Angeles County Jail houses 5,000 inmates with mental illness, making it the largest treatment facility in the country. This is as inhumane as it is ineffective.  Mentally ill people incarcerated for nonviolent offenses have been held naked and handcuffed to tables to prevent movement, receiving no treatment other than psychotropic medication. Research commissioned by the Los Angeles County Board of Supervisors in 2018 estimated that up to 68% of the jail mental health population could be diverted out of jail, if there were housing or treatment beds available.  

This criminalization of mental illness comes at a price: In Los Angeles County, it costs five times as much to incarcerate people with behavioral health needs than it does to offer in-patient treatment. 

Seeing people with behavioral health needs on our streets leads people to feel — not without reason — that there has been a fundamental breakdown of the social order, which makes people feel unsafe. In the worst cases, a person with untreated mental illness harms someone. And there is no true safety for those forced to live on the streets with untreated health needs. 

No city in California is immune from — nor responding adequately to — this crisis. 

We must adequately fund our non-law enforcement crisis response teams, so that social workers — rather than police — are available to respond to situations arising from mental illness or substance use disorders. We must expand the hours and availability of treatment facilities. Each agency must work to get people to health solutions that can improve their lives and build safer communities.  

Public safety is public health — for everyone. 

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Chesa Boudin is convening experts from 9 a.m. to 1:30 p.m. on Wednesday, July 28, to discuss the need for public health responses to behavioral health needs. Sydney Kamlager is the keynote speaker. Watch here: https://www.facebook.com/SFDistrictAttorney.

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Sydney Kamlager has previously written about cost-sharing for abortion.