How CARE Court lost its teeth in the California Legislature

California's CARE Court Falls Far Short of Promises to Remove Mentally Ill From Streets

Legislative Amendments Stripped Program of Enforcement Powers, Creating 'Court With No Real Power'

BLUF (Bottom Line Up Front): California's Community Assistance, Recovery, and Empowerment (CARE) Court program, launched in October 2023 to address severe mental illness and homelessness, has enrolled just 528 people in treatment through July 2024—far below the 7,000-12,000 annually projected by Governor Gavin Newsom. The program overwhelmingly relies on voluntary agreements (514 of 528 cases) rather than court-ordered treatment plans, has issued zero fines to counties for failure to provide services, and refers almost no one to conservatorships. Most CARE Court participants are not homeless, and the program has proven ineffective at removing mentally ill individuals from California's streets as originally promised.

Program Performance Falls 93 Percent Below Projections

When Governor Gavin Newsom unveiled CARE Court in March 2022, he described it as a "paradigm shift" with "real power" to mandate treatment for severely mentally ill Californians and hold counties accountable for providing services. The governor estimated the program would serve 7,000 to 12,000 people annually once fully implemented across all 58 counties.

The reality has proven dramatically different. According to the California Judicial Council, only 2,421 petitions were filed through July 2024, resulting in just 528 treatment agreements or plans—representing less than 7 percent of the low-end projection. An additional 362 people were diverted to other county services without formal CARE Court enrollment.

"It's going much more slowly than we thought it would," Lisa U'Ren, former board member of the National Alliance on Mental Illness in Solano County, told reporters in September.

Los Angeles County, which leads the state with 511 petitions filed, had predicted enrolling 4,500 people in the first year but achieved only 112 care agreements or plans. San Diego County anticipated 1,000 petitions and 250 court-ordered treatment plans in year one but received only 384 petitions and established 134 voluntary agreements—with zero court-ordered plans.

Legislative Process Gutted Original Enforcement Mechanisms

A comprehensive CalMatters review of the legislative record reveals that CARE Court underwent substantial amendments between Newsom's March 2022 announcement and the bill's September 2022 passage, fundamentally altering its structure and enforcement capabilities.

Key changes included:

Narrowed Eligibility: The original proposal covered mental illness and substance use disorders. The final law restricts eligibility to adults with untreated schizophrenia or other psychotic disorders who meet seven specific criteria, creating what critics describe as an unnecessarily narrow scope.

Prioritized Voluntary Agreements: An April 2022 amendment prioritized "settlement agreements"—voluntary treatment plans—over court-ordered plans. The law now requires judges to first attempt voluntary agreements, only ordering treatment plans when voluntary cooperation appears unlikely.

Weakened County Accountability: While Newsom promised counties could face fines up to $1,000 daily for failing to provide court-ordered services, no such fines have been imposed. The law relies on what State Senator Tom Umberg, the bill's co-author, described as the "soft power" of judges rather than concrete enforcement mechanisms.

Increased Petitioner Requirements: Amendments tightened timelines and added documentation requirements for those filing petitions, including mandatory attendance at initial hearings—a barrier for overworked first responders and family members facing federal privacy laws that complicate proving a loved one's condition.

"I think the law that was promised was pretty ambitious," said Assemblymember Ash Kalra, a San Jose Democrat and the only lawmaker to consistently oppose the 2022 measure. "It's not surprising to me that it didn't live up to all the hype of what was promised."

Court-Ordered Plans Virtually Nonexistent

The most striking disparity between Newsom's vision and implementation involves court-ordered treatment plans—the mechanism intended to compel participation from individuals who refuse voluntary services.

Through July 2024, California courts ordered just 14 treatment plans statewide, compared to 514 voluntary agreements. In San Francisco, which received 42 petitions through September 2024, zero court-ordered plans have been issued. San Diego County, with 384 petitions, established 134 voluntary agreements but no mandatory plans.

"We don't mandate involuntary treatment in the CARE Act at all," Los Angeles County Superior Court Judge Scott Herin stated at a November hearing. "It is at the discretion of the individual to accept them."

This reality contradicts Newsom's March 2022 statements emphasizing that CARE Court would have "specific stepped up sanctions" and that "the courts initiate the CARE plan and the process." The governor described the program as providing consequences for noncompliance, warning that participants failing the program could face conservatorship referrals.

Zero Conservatorship Referrals, Zero County Fines

Two pillars of Newsom's original accountability framework—conservatorship referrals for program failures and financial penalties for counties not providing services—have failed to materialize.

Despite the legislative language allowing conservatorship referrals when individuals cannot successfully complete court-ordered plans, no such referrals have been documented in available data. This outcome stems partly from the paucity of court-ordered plans themselves, but also reflects judges' reluctance to pursue this more restrictive option.

Similarly, although the law authorizes courts to fine counties up to $1,000 daily for failing to meet their obligations under court-ordered CARE plans, and even appoint agents to ensure service provision in extreme cases, no county has been fined or had an agent appointed.

"I don't think that we've done the kind of job that needs to be done," Senator Umberg acknowledged. "Do we need to have more folks who are engaged and successfully complete the program? Absolutely. Have we gotten there yet? No."

Most Participants Not Homeless; Housing Remains Elusive

Analysis of county-level data reveals that CARE Court has not functionally addressed street homelessness as prominently advertised. In Los Angeles County, fewer than one-quarter of the 629 petitions filed through October 2024 involved homeless individuals. Most petitions come from family members for relatives who maintain some housing stability.

For homeless participants who do enter the program, housing assistance proves challenging. The CARE Act provides priority access to existing state housing funds but includes no dedicated housing appropriation. Counties receive $72 million for startup costs and $12 million for ongoing operations in fiscal year 2024-25, increasing to $47 million in 2026-27—funds designated for court operations and clinical evaluations rather than housing construction.

"Without guaranteed permanent housing, CARE Court is merely 'window-dressing,'" said Eve Garrow, senior policy analyst with the ACLU of Southern California, which opposed the legislation.

In San Diego County, officials report that some homeless CARE Court participants placed in temporary bridge housing subsequently leave and return to the streets. "What's been hard there is just seeing folks come to us and then not stay," said county program coordinator Amber Irvine. "I didn't really anticipate that, but in hindsight, it does make sense."

Newsom's administration cut $132.5 million in fiscal year 2024-25 and $207.5 million the following year from the Behavioral Health Bridge Housing Program—the intended primary housing source for CARE Court participants—as part of budget deficit reduction measures.

High Dismissal Rates Compound Low Petition Numbers

California courts dismiss approximately 45 percent of CARE Court petitions statewide, though this figure includes the small number of cases where individuals successfully graduated from the program. San Francisco's dismissal rate reaches nearly two-thirds.

Reasons for dismissal include failure to meet the narrow diagnostic criteria, petitioner non-appearance at hearings, and inability to locate the subject of the petition. The requirement that petitioners attend initial court hearings poses particular challenges for first responders and behavioral health workers whose schedules cannot accommodate court appearances.

To address this barrier, some counties have modified their approach. Alameda County now allows first responders and outreach workers to refer homeless clients to the county, which then files the petition on their behalf.

Few Graduations Despite Two Years of Operation

Very few individuals have successfully completed CARE Court despite the program's October 2023 launch. Los Angeles County, with the most petitions statewide, reports zero graduations. The first graduation occurred in San Diego County in August 2024.

Nine counties have operated CARE Court long enough for participants to complete the minimum one-year program duration, yet graduation data remains sparse. The California Department of Health Care Services and Judicial Council have not released comprehensive graduation statistics.

Political Implications and Future Modifications

The stakes are significant for Governor Newsom, who has tied his political legacy to addressing California's homelessness and mental health crises. Following CARE Court's creation, the administration secured passage of Senate Bill 43 in 2023, expanding conservatorship eligibility criteria, and championed Proposition 1 in March 2024, authorizing $6.4 billion in bonds for behavioral health facilities and housing.

In September 2024, Newsom signed Senator Umberg's Senate Bill 42, described as a "cleanup" measure intended to streamline CARE Court operations by improving the petition process and facilitating communication between stakeholders. The bill also clarified that healthcare facilities can refer patients from involuntary psychiatric holds to CARE Court rather than conservatorship proceedings.

However, estimates of SB 42's impact vary wildly. San Diego County projects the bill could increase its CARE Court numbers anywhere from 3.5 percent to 48.1 percent—a range reflecting fundamental uncertainty about program dynamics.

"They're not trying to fix a problem, they're trying to deliver political optics, and that's all this ever was," said Lex Steppling, founding member of the All People's Health Collective, a disability rights organization.

Administration Defends Program, Criticizes Counties

When asked whether the accountability mechanisms he promoted in 2022 had materialized, Newsom did not directly respond, according to CalMatters. Instead, spokesperson Tara Gallegos emphasized that the program's "core" was always "voluntary" participation, stating that "coercion rarely works with those who need care."

Gallegos adopted a sharper tone regarding counties: "It shouldn't take stronger accountability measures for counties to do the right thing. The public has called for action and counties should be listening and acting with urgency—or voters will do it for them. There's no excuse for counties failing to deliver—and the variability in implementation that we are seeing now is completely unacceptable."

This statement contradicts the administration's emphasis on voluntary participation, as stronger accountability measures would necessarily involve more coercion.

Dr. Mark Ghaly, outgoing Secretary of California's Health and Human Services Agency, urged patience. "To really make some grand statement about its efficacy in the first 12 months of it rolling out, I think, is a leap for a state with 40 million people," he told KQED. "But I do think that's exactly the question that we have to keep in mind."

A December 2024 administration press release claimed that "over 1,400 people have been connected to CARE Courts or to county services directly, based on preliminary data" and that the program is "making a significant impact by addressing some of the most serious cases of mental health crises on California's streets."

Opposition Remains Vocal

Civil rights organizations that opposed CARE Court from inception maintain their criticism. Disability Rights California, which challenged the law's constitutionality (unsuccessfully), argues the program represents wasteful spending that fails to address root causes.

"We feel like the program has already failed," said Samuel Jain, senior mental health policy attorney at Disability Rights California. "The bottom line is that the court is a coercive program."

Jain and other critics contend that California's mental health crisis stems from lack of affordable housing and inadequate voluntary mental health services, not from insufficient legal mechanisms to compel treatment. They note that CARE Court funding—projected at approximately $300 million annually for full implementation—supports court operations rather than expanding treatment capacity or housing availability.

The American Civil Liberties Union of Southern California argues that CARE Court creates perverse incentives, potentially causing individuals who need help to avoid the mental health system or even family members who might file petitions against them.

Some Supporters Remain Optimistic

Despite disappointing numbers, some mental health professionals and local officials express cautious optimism, viewing CARE Court as a work in progress requiring time to establish procedures and build trust with potential participants.

"The most important ingredient for a successful program is collaboration among all the stakeholders," said Orange County Superior Court Judge Ebrahim Bayteih, whose county participated in the pilot program.

Judge Michael Begert, who presides over San Francisco's CARE Court, emphasizes the program's voluntary approach. "Coerced treatment is very much 'what we're trying to avoid,'" he said. However, he acknowledged the challenge of changing established cultures in both the court system and mental health care system.

Sacramento Mayor Darrell Steinberg, founder of the Steinberg Institute which supported CARE Court, maintains that "the State CARE court system provides counties and cities with a crucial legal tool. We must use this tool to intensify our efforts, ensuring that more vulnerable individuals receive the mental and behavioral health care, housing, and supportive services they desperately need."

The National Alliance on Mental Illness of California, which backed the legislation, has not withdrawn its support despite implementation challenges.

Broader Context: California's Homelessness Statistics

CARE Court operates against the backdrop of California's persistent homelessness crisis. The state conducted its annual point-in-time count in January 2024, with results released in December 2024 showing that California's overall homelessness increased 3 percent while the national rate increased over 18 percent. California's unsheltered homelessness grew just 0.45 percent compared to the national increase of nearly 7 percent.

However, these figures reflect broader statewide trends unattributable to CARE Court specifically, given the program's limited enrollment and recent implementation. California contains approximately one-third of the nation's homeless population despite representing 12 percent of the U.S. population. An estimated one in four homeless Californians has serious mental illness.

Assessment: Promise Versus Reality

The CalMatters analysis of legislative amendments proves accurate: CARE Court as enacted differs substantially from Newsom's March 2022 proposal. The program's reliance on voluntary participation, minimal use of court-ordered treatment plans, absence of county fines or conservatorship referrals, and failure to reach projected enrollment numbers support characterizations of CARE Court as having "no real power," as San Diego mother Anita Fisher stated after calling the program a "total failure" in practice.

Whether the program's shortcomings stem from flawed design, inadequate funding, insufficient time for implementation, or unrealistic initial projections remains subject to interpretation. What appears indisputable is that CARE Court has not functionally addressed California's street homelessness crisis or removed significant numbers of severely mentally ill individuals from public spaces as prominently advertised.

The program's future trajectory depends on pending legislative modifications, county implementation effectiveness as all 58 counties complete rollout, and the political will to either substantially reform or abandon the approach. With an estimated $300 million in annual operational costs once fully implemented, CARE Court represents a significant public investment whose return remains uncertain.

As California continues wrestling with intertwined crises of homelessness, mental illness, and substance abuse, CARE Court stands as a case study in the gap between legislative intention and practical implementation—a court system conceived with enforcement authority but transformed through the political process into a framework emphasizing voluntary compliance, with predictable results.

Verified Sources and Citations

Government and Judicial Sources

California Judicial Council. (2024, January 19). "California Courts Report Successful Start to CARE Act." California Courts Newsroom. Retrieved from https://newsroom.courts.ca.gov/news/california-courts-report-successful-start-care-act
California Judicial Council. (2024, December). "2024 Year in Review: Judicial Council of California." Judicial Branch of California. Retrieved from https://courts.ca.gov/news/2024-year-review-judicial-council-california
California Judicial Council. (2024). "CARE Act Overview." California Courts Newsroom. Retrieved from https://newsroom.courts.ca.gov/care-act/overview
California Governor's Office. (2022, March). "California's CARE Court Fact Sheet." Retrieved from https://www.gov.ca.gov/wp-content/uploads/2022/03/Fact-Sheet_-CARE-Court-1.pdf
California Governor's Office. (2024, December 2). "Successes Continue to Grow as CARE Court Opens in All 58 California Counties." Retrieved from https://www.gov.ca.gov/2024/12/02/successes-continue-to-grow-as-care-court-opens-in-all-58-california-counties/
California Governor's Office. (2024, December 27). "California Outperforms the Nation in Reducing the Growth of Homelessness." Retrieved from https://www.gov.ca.gov/2024/12/27/california-outperforms-the-nation-in-reducing-the-growth-of-homelessness-state-sees-largest-decrease-in-veteran-homelessness-in-the-nation/
California Governor's Office. (2025, August 18). "Reporting Shows Reduced Homelessness in Communities Throughout California." Retrieved from https://www.gov.ca.gov/2025/08/18/reporting-shows-reduced-homelessness-in-communities-throughout-california/
California Department of Health Care Services. (2024, July 31). "CARE Act Frequently Asked Questions." CARE Act Resource Center. Retrieved from https://care-act.org/library/faqs/

News Organizations and Analysis

Yu, Yue Stella and Erica Yee. (2024, December). "How CARE Court Lost Its Teeth in the California Legislature." CalMatters via Times of San Diego. Retrieved from https://timesofsandiego.com
Kendall, Marisa. (2025, September 8). "Newsom Promised Real Progress on Mental Health With CARE Court. Here's What the Numbers Show." CalMatters. Retrieved from https://calmatters.org/health/mental-health/2025/09/care-court-2025-data/
Kendall, Marisa. (2025, December 18). "CARE Court Was Created to Help California's Toughest Homeless Cases. Why That's Been So Hard." CalMatters. Retrieved from https://calmatters.org/housing/homelessness/2025/12/care-court-homeless/
Wiener, Jocelyn. (2022, September 14). "California Homeless: How Will CARE Courts Work?" CalMatters. Retrieved from https://calmatters.org/housing/2022/09/california-lawmakers-approved-care-court-what-comes-next/
Paul-Brown, Sarah. (2024, January 29). "CARE Court Was Supposed to Help Those Hardest to Treat. Here's How It's Going." KQED. Retrieved from https://www.kqed.org/news/12007175/care-court-was-supposed-to-help-those-hardest-to-treat-heres-how-its-going
Torres, Phil. (2025, September 2). "What California's CARE Court Data Show." iNewsSource. Retrieved from https://inewsource.org/2025/09/02/san-diego-ca-care-court-data/
White, Jeremy. (2024, December 13). "California's 'Care Courts' Are Falling Short." KFF Health News. Retrieved from https://kffhealthnews.org/news/article/health-brief-california-care-courts-falling-short/
Fernandes, David. (2024, December 9). "CARE Court in Sacramento: What Family Members and Respondents Need to Know." CapRadio. Retrieved from https://www.capradio.org/articles/2024/12/09/care-court-in-sacramento-what-family-members-and-respondents-need-to-know/
Editorial Board. (2023, December 30). "Will CARE Courts and Conservatorship Actually Make a Difference on California's Streets in 2024?" San Francisco Chronicle. Retrieved from https://www.sfchronicle.com/opinion/editorials/article/california-care-courts-conservatorship-18561576.php
Kendall, Marisa. (2024, May 11). "Newsom Proposes Deeper Cuts to California Homeless Programs." CalMatters. Retrieved from https://calmatters.org/housing/2024/05/may-revise-2024-homeless-housing/
Trombley, Breanna. (2025, March 10). "San Diego's CARE Court Is Serving Those Formerly in Conservatorships." Voice of San Diego. Retrieved from https://voiceofsandiego.org/2025/03/10/san-diegos-care-court-is-serving-those-formerly-in-conservatorships/
Fernandez, Alicia A. (2024, May 17). "San Mateo County to Launch Mental Health 'CARE Court' to Bring Homeless People Off Street." The Mercury News. Retrieved from https://www.mercurynews.com/2024/05/17/san-mateo-county-to-launch-mental-health-care-court-to-bring-homeless-people-off-street/
Fretland, Amanda. (2024). "CARE Court Up and Running So How Effective Is It?" Ceres Courier. Retrieved from https://www.cerescourier.com/news/local/care-court-and-running-so-how-effective-it/
Sapien, Joaquin. (2022, November 3). "Care Courts: California Focuses on Mental Illness to Reduce Homelessness." The Christian Science Monitor. Retrieved from https://www.csmonitor.com/USA/Society/2022/1027/Care-Courts-California-focuses-on-mental-illness-to-reduce-homelessness

Advocacy and Legal Organizations

Charness, Michelle. (2024, March 6). "CARE Court or Scare Court? The California CARE Court System Allows for Involuntary Mental Health Treatment." Western Center on Law & Poverty. Retrieved from https://wclp.org/care-court-or-scare-court-the-california-care-court-system-allows-for-involuntary-mental-health-treatment/
Disability Rights California. (2024). "State of the State: California Disability Policy in 2024." Retrieved from https://www.disabilityrightsca.org/latest-news/state-of-the-state-california-disability-policy-in-2024

Legal and Policy Analysis

Silver, Matthew R., Lauren E. Brown, and Natalie Sahagun. (2024, January 1). "How Does CARE Court, California's New Legal Approach to Behavioral Health Care, Work?" Western City Magazine. Retrieved from https://www.westerncity.com/article/how-does-care-court-californias-new-legal-approach-behavioral-health-care-work
Judicial Council of California. (2023). "CARE Act Rules: Report to the Judicial Council." Retrieved from https://courts.ca.gov/system/files?file=itc/w23-10.pdf

County Government Sources

Santa Clara County Social Services Agency. (2024). "Public Administrator, Guardian, Conservator: CARE Act Information." Retrieved from https://ssa.santaclaracounty.gov/protective-services/public-administrator-guardian-conservator
San Bernardino County Department of Behavioral Health. (2024). "CARE Act Program Information." Retrieved from https://wp.sbcounty.gov/dbh/careact/
Superior Court of California, County of Ventura. (2024). "CARE Act Program." Retrieved from https://www.ventura.courts.ca.gov/care.html

Note on Fact-Checking:

This article's core assertions—that CARE Court has enrolled 528 people through July 2024 versus projections of 7,000-12,000 annually, that 514 of 528 cases involve voluntary agreements rather than court orders, that no counties have been fined, and that the program has not significantly removed homeless individuals from California's streets—are corroborated by multiple independent sources including government data from the California Judicial Council, investigative reporting by CalMatters and KQED, and statements from program administrators and participants.

The assertion that legislative amendments substantially changed the program from Newsom's original vision is documented through CalMatters' review of successive bill versions and confirmed by statements from legislators including the bill's co-author Senator Umberg and opponent Assemblymember Kalra.

All direct quotations are sourced to specific published interviews or official statements. Statistics on homelessness trends, program enrollment, petition dismissals, and budget allocations come from official government sources or confirmed county reporting.

SIDEBAR: Six Decades of Broken Promises—How America Abandoned Its Mentally Ill

From Asylums to Streets: The Unfulfilled Vision of Community Care

The helplessness families feel when watching a loved one with severe mental illness spiral into crisis while unable to compel treatment represents not just personal tragedy, but the culmination of six decades of failed mental health policy—a story of noble intentions systematically undermined by inadequate funding, shifting political priorities, and the collision between civil rights and public health.

The Kennedy Vision: 1963

On February 6, 1963, President John F. Kennedy delivered the first—and perhaps only—presidential message to Congress devoted exclusively to institutionalization. His vision was transformative: replace the nation's overcrowded state psychiatric hospitals with a network of 1,500 community mental health centers that would provide humane, local care. Kennedy promised to "cut by half, within a decade or two, the 600,000 persons now institutionalized for psychological disorders."

His personal connection was profound. Kennedy's sister Rosemary had undergone a lobotomy that significantly worsened her quality of life, giving the president intimate knowledge of both the failures of institutional care and families' desperate searches for alternatives.

Kennedy's optimism was grounded in recent pharmaceutical advances. The introduction of chlorpromazine (Thorazine) in 1954 and subsequent antipsychotic medications suggested that severe psychotic and mood disorders—previously considered intractable—could be managed in community settings. The psychiatric profession, despite internal divisions between biological and psychosocial approaches, largely supported this vision.

On October 31, 1963, Kennedy signed the Community Mental Health Centers Act into law. Three weeks later, he was assassinated. The bill would be the last legislation he ever signed.

The Collapse of Community Care

Kennedy's death proved catastrophic for his mental health vision. Federal enthusiasm for funding the promised community centers evaporated. By 1980, only about half of the planned 1,500 centers had been constructed. None received full funding. No follow-up legislation established ongoing operational support.

Yet the exodus from psychiatric hospitals continued unabated.

In 1955, America's state and county psychiatric hospitals housed 558,922 patients—representing approximately 50 percent of all hospital beds in the United States. The population declined modestly to about 500,000 by 1965, then plummeted. By 1980, fewer than 132,000 remained in state hospitals. By 2014, the number had fallen to approximately 37,000—a 93 percent reduction from the 1955 peak.

Adjusted for population growth, the decline was even more dramatic: from 339 psychiatric beds per 100,000 Americans in 1955 to just 22 per 100,000 by 2000—a 93.5 percent decrease in per-capita capacity.

The Perfect Storm: Multiple Policy Failures

Deinstitutionalization succeeded not through careful planning but through the convergence of multiple forces, many driven by cost-shifting rather than patient welfare:

Federal Funding Incentives: The 1965 enactment of Medicaid under President Lyndon Johnson specifically excluded inpatient psychiatric hospital care from federal reimbursement, but covered nursing homes and community-based care. This provision created powerful financial incentives for states to close psychiatric hospitals and transfer costs to the federal government. States could shift approximately 50 percent of costs by moving patients from state hospitals—which received no federal reimbursement—to settings eligible for Medicaid matching funds.

California's Pioneer Role: In 1967, then-Governor Ronald Reagan signed California's Lanterman-Petris-Short (LPS) Act, which dramatically narrowed the circumstances under which individuals could be involuntarily committed for psychiatric treatment. The law established that people could only be held if they were a danger to themselves or others, or "gravely disabled"—defined narrowly as unable to provide food, clothing, or shelter. The legislation prioritized civil liberties protection but provided no corresponding expansion of voluntary treatment capacity.

Former California Governor Edmund "Pat" Brown, who oversaw the beginning of deinstitutionalization in the early 1960s, later expressed regret. "They've gone far, too far, in letting people out," Brown told The New York Times in 1984.

The LPS Act's impact was immediate and ominous. The number of mentally ill people entering California's criminal justice system doubled in the first year following enactment—a preview of the "criminalization of mental illness" that would sweep the nation.

The Carter-Reagan Budget Collapse: In 1980, President Jimmy Carter signed the Mental Health Systems Act, designed to bolster federal support for community-based care for people with chronic mental illness. However, Carter lost reelection that November, and in 1981, President Reagan signed budget legislation that repealed virtually all provisions of Carter's act and cut federal mental health funding by approximately one-third. Remaining federal funds were converted to mental health block grants to states, ending any pretense of a coordinated national approach.

From Hospitals to Jails: Trans-Institutionalization

What advocates called "deinstitutionalization" critics increasingly termed "trans-institutionalization"—the shift of mentally ill Americans from one form of confinement to another, but without treatment.

The trajectory was inexorable. In 1978, California's prison population stood at approximately 25,000. By 2006, it had exploded to over 170,000, with 30 percent designated as needing mental health services. Between 1970 and 1992, the inpatient population in state psychiatric hospitals decreased 77 percent nationwide while the nation's prison and jail populations surged.

By 2011-2012, an estimated 44 percent of jail inmates had mental illness—up from 16 percent in 1976. The three largest mental health treatment facilities in America became jails: Los Angeles County Jail, Chicago's Cook County Jail, and New York's Rikers Island.

Criminal justice professionals developed bleak terminology for the pattern: "life on the installment plan." Mentally ill individuals would commit low-level crimes, get arrested, receive stabilization in jail (regular meals, sleep, medication), be released, decompensate without community support, commit another offense, and return to custody—cycling endlessly through a system designed for punishment rather than treatment.

The Demographics of Abandonment

The population shifted out of state hospitals was broader than generally understood. In 1970, patients aged 65 and older represented 29.3 percent of residents in state and county psychiatric hospitals, many with dementia and other conditions now rarely treated in psychiatric facilities. By 2014, this group had declined to just 8.8 percent—many transferred to nursing homes or left with families.

But even accounting for elderly patients now receiving care elsewhere, the reduction in capacity for younger adults with serious mental illness was catastrophic. Conservative estimates suggest at least 178,000 fewer hospital beds available between 1970 and 2014 for non-elderly patients with severe psychiatric conditions.

Where did they go? Studies from the late 1980s indicated that one-third to one-half of homeless Americans had severe psychiatric disorders, often complicated by substance abuse. Contemporary estimates of severe mental illness among the homeless range from 21 percent to as high as 80 percent, depending on how broadly disability is defined.

The Failed Promise of Community Resources

The community mental health centers that were built often failed to serve the most seriously ill. Centers' caseloads expanded to include people with less severe but still distressing conditions—those more likely to cooperate with treatment, show measurable progress, and generate positive program statistics.

People with schizophrenia and other psychotic disorders—those most in need of structured support—frequently found themselves neglected. Community treatment programs lacked the resources, staffing, and authority to provide the intensive, sustained intervention required for those with the most severe illnesses.

Ironically, some innovative programs emerged from this wreckage. In 1972, clinicians in Madison, Wisconsin, launched Assertive Community Treatment (ACT), an intensive multidisciplinary approach providing treatment, medication management, and practical skill-building for people with severe mental illness. But such programs remained exceptions rather than the rule, limited by funding and scattered across jurisdictions with widely varying commitment to mental health.

The Civil Rights Dilemma

Deinstitutionalization coincided with—and was partly driven by—the civil rights movements of the 1960s and 1970s. Psychiatric patients' rights advocates, drawing inspiration from broader movements for racial equality and disability rights, challenged the power of the state to confine and treat individuals against their will.

The Insane Liberation Front, founded in Portland, Oregon, in 1969, pioneered ex-patient activism. Publications like the Madness Network News advanced what they termed "critical psychiatry," questioning medical authority over mental illness itself. By the 1980s, a robust consumer/survivor/ex-patient movement championed individual autonomy and opposed coercive treatment.

These advocacy efforts corrected real abuses. State hospitals had, in too many cases, warehoused patients in deplorable conditions with little therapeutic benefit. Exposés published during and after World War II—when conscientious objectors assigned to mental hospitals witnessed horrific conditions—had shocked the public. Forced treatment without adequate safeguards had robbed countless individuals of liberty and dignity.

But the pendulum swung dramatically. Civil liberties protections were layered on without corresponding expansion of voluntary services. The result: people too ill to recognize their need for treatment, yet not meeting increasingly narrow criteria for involuntary commitment, cycled through emergency rooms, jails, and street homelessness.

The Situation Today

The consequences of six decades of failed policy reverberate through every American community. Current estimates suggest the United States needs approximately 35-50 psychiatric beds per 100,000 population to adequately serve those with serious mental illness. Most states fall far short. As of 2014, the nation averaged approximately 53.6 residents in psychiatric inpatient and residential treatment beds per 100,000—but this includes private facilities, general hospital units, and residential treatment centers, many focused on short-term stabilization rather than the sustained care required for severe, chronic conditions.

State psychiatric hospitals—once the backbone of America's mental health infrastructure—provide only about 11 beds per 100,000 population, roughly 3 percent of 1955 levels. The gap has not been filled by community resources.

Families living with this failure know the bitter reality: watching a loved one deteriorate, unable to compel treatment until they meet narrow criteria for dangerousness, then watching them cycle through brief crisis interventions before returning to the street. The process repeats, often for years or decades, until tragedy or incarceration intervenes.

CARE Court in Historical Context

California's CARE Court represents the latest attempt to thread an impossible needle: compelling treatment for those unable to recognize their need while respecting civil liberties, providing intensive services without adequate funding, and holding counties accountable for delivering resources they don't possess.

It is, in many ways, a familiar story—another well-intentioned program launched with optimistic projections and insufficient infrastructure, creating hope that will likely be disappointed.

The difference between Kennedy's 1963 vision and Newsom's 2022 CARE Court is largely rhetorical. Both promised revolutionary change. Both relied on community-based care without guaranteeing funding. Both confronted the fundamental tension between liberty and coercion in treating mental illness. Kennedy's promise produced 50 percent of planned centers, never fully funded. Newsom's promise has produced 7 percent of projected enrollments, with minimal use of court-ordered treatment.

History suggests the pattern will continue: initial enthusiasm, gradual realization of resource constraints, quiet scaling back of expectations, and ultimately, another generation of families left helpless as their loved ones suffer on America's streets and in its jails.

The Unlearned Lesson

The American Journal of Psychiatry, reviewing Kennedy's Community Mental Health Act, concluded: "The CMHA and its failings teach us that optimism without infrastructure slows the path to success." Sixty years later, policymakers apparently have not internalized this lesson.

What families facing mental illness in their loved ones need is not another program with grand ambitions and inadequate resources. They need sustained, adequately-funded, comprehensive treatment systems with both voluntary and, when medically necessary, involuntary components—a true continuum of care from intensive inpatient treatment through structured community support.

They need, in short, what Kennedy promised in 1963 but never delivered. Until that promise is kept—not just announced but actually funded and implemented—the cycle of hope, disappointment, and tragedy will continue.

The question is not whether America can afford such a system. The question is whether it can afford the continued cost of failure: streets lined with suffering, jails packed with the mentally ill, families living in helpless anguish, and lives destroyed by untreated, treatable illness.

Sources

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