Complex Strategy Leads To Success of MH Initiative

California voters passed Proposition 63 in November 2004, a ballot initiative that authorizes a 1 percent tax on annual adjusted gross income over $1 million to support county-operated mental health systems.

The tax will result in an estimated $1.8 billion in new revenues over the first three years.

What lessons does this legislation hold for mental health advocates who are struggling with erosion in financial support for services in other sections of the country?

Health policy analysts Richard Scheffler and Neal Adams tackled that question in “Millionaires and Mental Health: Proposition 63 in California” in the May 3 Health Affairs. They noted that California's history of allowing voters to bypass the legislative process and place initiatives on the ballot dates back to 1911. Since then, voters approved 104 of the 303 initiatives that qualified for the ballot.

Only 12 initiatives affecting taxes passed. Of those, only three, including Proposition 63, increased taxes.

Proposition 63 passed with a majority of 53.8 percent. In the same election, Proposition 72, which would have expanded employer responsibility for health care coverage, failed by a small margin.

Passage had “much visible support and little visible opposition,” according to the authors.

Randall Hagar, director of government affairs for the California Psychiatric Association (CPA), shares that opinion and worked to develop that support.

The CPA was a member of the group that drafted the ballot initiative, he said, and later was represented on the steering committee of the Campaign for Mental Health, which led the effort (Psychiatric News, December 3, 2004).

The campaign commissioned polls and focus groups to help with its planning.

“We knew we had a winner when the results came back,” said Hagar. “Respondents overwhelmingly replied affirmatively to the question, `Have you or someone you know suffered from a serious mental illness?'”

He believes the strong positive response represents a major change in public perception that signals a decrease in stigma in the last 10 years.

The phrase “everyone knows someone with mental illness” became a key theme of the campaign.

Supporters raised $4.3 million, and opponents raised $17,500. Top contributors to passage included the California Council of Community Mental Health Agencies, California Healthcare Association, California State Council of Service Employees Issues Committee and other unions, and Mental Health Association of Los Angeles County.

APA, which gave $25,000 to the campaign, was the only national organization to make a contribution. Hagar said, “Members of the steering committee were duly impressed.”

The CPA assisted its five district branches to raise money and secured the support of the California Medical Association. Donations from California physicians reportedly exceeded $100,000, according to Hagar.

Scheffler and Adams noted, “The pitch that mental health treatment works was credible and easy to deliver.”

Proposition 63 built on the success of legislative initiatives sponsored by Assemblyman Darrell Steinberg (D). The resulting program, which targeted mental health services to people who were homeless, was cited as a model in the 2003 report of the New Freedom Commission on Mental Health.

Hagar also credits earlier work by Assemblywoman Helen Thomas (D), who introduced a bill to make mental health services an entitlement. That bill“ served as an inspiration and template for Proposition 63,” he said.

Scheffler and Adams listed six primary arguments in favor of passage of Proposition 63 (Original article: see box).

To determine the sources of voter support for Proposition 63, the authors examined the independent effect of a number of variables at the county level.

Scheffler and Adams found the percentage of registered Democrats to be highly significant and positively correlated to a “yes” vote.

The percentage of Hispanic population was highly significant but negatively correlated to a “yes” vote. The authors speculate that the reasons could be differences in the perceived need for mental health services as compared with other voters and the lack of cultural competence in the service delivery system.

The rate of homelessness was positively correlated with a “yes” vote but was statistically weak. The authors substituted statewide average data on homelessness for county data when the latter was unavailable.

The authors called Proposition 63 “a landmark piece of mental health and fiscal legislation” and noted that the mental health community in California and the nation will be watching carefully to see what happens.

Hagar said, “We convened a task force that is working on such issues as the development of state guidelines for the expenditure of funds.”

He expects that funds from Proposition 63 could become available to county governments as early as September, although the amounts have yet to be determined.

“Millionaires and Mental Health: Proposition 63 in California” is posted at<http://content.healthaffairs.org/cgi/reprint/hlthaff.w5.212v1>.▪