California law, Welfare and Institutions Code Section 17000, has required counties to provide health care for the poor since 1933. Counties have done so in a variety of ways with varying programs led by county boards of supervisors in partnership with public health officers. The law requires counties to provide relief and support, for incompetent, poor, or indigent persons and those incapacitated by age, disease or accident. 

A further breakdown of responsibilities assumed include: alcohol and drug abuse services for the general public; necessary medical, dental, psychiatric, and substance abuse services for the incarcerated; general environmental health; local emergency medical services and planning; medical care for the indigent who are not categorically linked to other public health insurance programs; medically indigent adults; mental health services ranging from acute inpatient care to local crisis services and outpatient care; public health prevention, intervention and education programs and services; and services for special-education students regardless of income.

To achieve this seemingly insurmountable obligation, these “providers of last resort” seek care models that best serve their respective populations. Each county decides how much emphasis to put on care for the indigent in relation to other spending priorities. Counties also choose how to balance inpatient and emergency services with primary care and outpatient services and what network of public and private providers will be used to deliver services.

For counties to fulfill such a task is very challenging. What is clear is that counties can’t do this alone. Best practices have emerged from across the state and a significant number of public private partnerships formed around implementation strategies for each segment of care. Program funding mechanisms, opportunities and needed resources being at the center of each debate.

To peel away at just one part of this discussion, let us look at the evolution of funding for mental health services. From the Short-Doyle Act of 1957 to the Lanterman-Petris-Short (LPS) Act of 1968, AB 3777 in 1988 and the realignment activities of the 1990s including Medi-Cal Mental  Health Managed Care-Consolidation and Capitation to the most recent Mental Health Services Act (MHSA) / Prop 63 of 2004. California is clearly not new to the discussion board on mental health programming and funding strategy. 

Up for discussion again is the use of MHSA funds. Originally intended to expand, not supplant, existing mental health services. Counties will continue to face increasing challenges while they try to manage their communities’ high expectations for system improvements. Best practices from across our state that better serve persons with mental illness should be examined closely.

California once led the nation in community mental health services development and civil rights for persons with mental illness – and can once again.