What reporters should keep in mind as California seeks to overhaul its approach to mental health and homelessness

In California, like many other states, people with serious mental illness often cycle through emergency rooms, jails and the streets. The state is facing a pivotal moment as policymakers attempt to overhaul the state’s mental and behavioral health care systems and get more people with substance abuse issues and mental illness off the streets, all part of a broader effort to address California’s staggering homelessness crisis.  

As votes were still being tallied on the landmark mental health measure Proposition 1 this week, a Center for Health Journalism panel at the 2024 California Health Equity Fellowship explored the sources of the crisis facing California and other states. San Diego journalist Lisa Halverstadt and Seattle-based journalist and podcast host Will James joined Brett Feldman, director of USC Street Medicine, to explain recent policy shifts and how reporters can cover this evolving story with authenticity.   

“California is in a moment where we see homelessness surging,” said Halverstadt, a senior investigative journalist with the Voice of San Diego. “While there are many disagreements about the response, everyone seems to agree that it's not working.”

What’s happening in California? 

California is pursuing multiple efforts to transform its fragmented behavioral health care system. Last year, Gov. Gavin Newsom signed Senate Bill 43, which updated conservatorship laws for the first time in decades. The new law, which revised the Ronald Reagan-era Lanterman-Petris-Short Act, or LPS, expanded conservatorship eligibility criteria to more Californians. 

“It essentially adds people with severe substance use disorder as eligible for a conservatorship and also lowers the bar or the definition of gravely disabled,” Halverstadt explained. 

Meanwhile, the CARE Act, which was signed into law by Newsom last year, created a new court process that could expand access to care plans for people with untreated schizophrenia and other psychotic disorders. Family members, medical professionals, and police can petition the court to compel government-funded treatment.

Just this week, voters weighed in on Proposition 1, which redirects an existing tax on the rich to pay for substance use disorder services. It also includes $6.4 billion to fund thousands of new behavioral health beds, outpatient substance use treatment, and housing — shifting money from the counties to the state. 

The measure “takes away some of the leeway that counties have to really … focus on chronically homeless population, sort of the people that have been deemed to be left behind by the public, which is quite controversial,” Halverstadt said. 

The legacy of deinstitutionalization 

California isn’t the only state grappling with the legacy of decisions made half a century ago, said James, who just launched a new podcast called “Lost Patients” exploring mental health and homelessness? in Washington state. 

“Essentially, you could view these reforms in their whole as an effort to reverse or make up for decisions that we made in the 1960s and 70s,” he said. 

Long-shuttered state psychiatric hospitals once housed thousands of people, from those with severe mental illness to people who were not accepted by society.

“They swept in huge populations of people who didn't belong there,” James said. “They kept them there with  very few rights. And eventually, a reform movement swept the country.”

The shuttering of those state hospitals led to a scattered system of smaller community-run mental health facilities that often catered to the “worried well,” or people who functioned in mainstream life with depression or anxiety. While the former state psychiatric hospitals — and their army of psychiatrists and nurses — provided deeply flawed care in many ways, the system then was centralized. 

Now, there’s “a landscape of diffuse, separate providers that do their job, their one job, sometimes well, but then send the patient off into the world where they often just sort of get lost in the space between these nodes of care,” he said. 

While California’s current reform efforts don’t represent a full mental health overhaul, they do serve as a mortar that seals some of the most obvious gaps in a fragmented system, he said. The efforts also demonstrate an understanding of housing’s key role as well as the mental health and substance use connection. 

“Our efforts to separate those two things are not have not been productive in the way we handle this population,” he said.

Street medicine delivers homeless care 

In Los Angeles, USC’s Street Medicine teams provide care where people experiencing homelessness actually reside.                                                          

We’re “going to the people under the bridges behind the dumpsters wherever they are and delivering care in their environment,” said Feldman, co-founder of USC Street Medicine.  

On the streets, the health care teams help people manage chronic conditions such as hypertension and diabetes as well as more immediate wound care needs. They can also treat substance use and mental health disorders — all without requiring a patient to enter a facility. 

The group is able to receive reimbursements through Medi-Cal, the state’s insurance program for low-income individuals, though they’re still negotiating contracts to ensure that their rates adequately reflect their patients’ health complexities, he said. 

How reporters can follow the developments 

As California seeks to address the growing crisis, it’s important for journalists to ask specific questions and follow up, veteran homelessness reporter Halverstadt said. For example, where will Proposition 1 funding actually put the extra beds? Will resistance from neighbors or zoning rules delay the implementation? 

When reporting on these questions, talk to frontline workers who see the firsthand impacts, she advised. And, when interviewing patients, be explicit about what it means to talk to a reporter, and what personal information will end up in the article.

“Some of the steps that we need to take to do no harm are a little bit different with these very vulnerable populations,” she said. 

Another tip from James: When reporting on people with complex behavioral health and substance use issues, lean into the complexity. That means not shying away from people with substance use disorders or criminal records. Restricting your reporting to sympathetic sources can breed distrust when people note the gap between those anecdotes and what they notice firsthand. 

“It sends a message that some people are beyond humanizing,” he said. “And I think our job is to reflect reality and find the humanity is in everyone's story.”