The Ballooning Crisis: Acute Services vs. Organized Care
The state continues an unbalanced and dangerous approach on mental health care
California’s mental health system is in crisis. For years, the State has expanded acute and locked services without a coordinated plan for recovery. As someone in long-term recovery from polysubstance addiction—and living with neurodivergence, misdiagnosed psychiatric disorders and complex PTSD—I’ve seen too many people like me languish in locked facilities long after they’re ready for discharge. The promise of dignity and real care is often lost in the churn.
The California Drug Medi-Cal Organized Delivery System (DMC-ODS), grounded in American Society of Addiction Medicine (ASAM) criteria, proves that structured, accountable, and coordinated systems deliver real recovery. Counties that opt in gain control, transparency, and integrated care that fosters successful outcomes. In Los Angeles County, the Substance Abuse Prevention and Control (SAPC) division makes this real by rewarding providers who show results in workforce development, care coordination, patient engagement, and medication-assisted treatment. Funding follows measurable progress, supporting innovation and integrated clinical, peer, and housing services—all built on DMC-ODS “step-up/step-down” care.
Yet these principles have not transformed our fractured mental health landscape. Outdated laws and contracts keep large agencies in control while small, community-based providers—and those most vulnerable—are left out. One major gap is the lack of frameworks like LOCUS (Level of Care Utilization System). LOCUS assesses six domains—risk of harm, functional status, medical/psychiatric needs, recovery environment, treatment engagement, and supports—to pinpoint what level of care someone needs at any given moment. It enables people to move up or down as needed, just like DMC-ODS does for addiction treatment.
If we brought both DMC-ODS accountability and LOCUS flexibility into mental health, we could build a system that rewards quality and recovery, not just quantity—and ensure every resident gets care in the right setting, at the right time.
Recent legislation, especially Senate Bill 43 (2023,) is accelerating civil commitments and pushing locked facilities for substance use disorder (SUD), blending medical care with detention. These policy shifts are outpacing our system’s ability to provide step-down and community supports. When many of us worked to delay SB 43’s rollout in Los Angeles County, it wasn’t because we opposed appropriate care—we simply knew the system wasn’t ready. Rapid implementation risks trapping people in cycles of restrictive, acute care for life.
Civil and disability rights advocates understand this truth. Keris Myrick of Unapologetically Black Unicorns says, “Mental health advocacy is democracy in action, but democracy only works when every voice is heard. When political decisions feel disconnected from those they claim to serve… that is our fight now as it was 35 years ago.” Lex Steppling of All Peoples Health Collective adds, “They’re not trying to fix a problem, they’re trying to deliver political optics, and that’s all this ever was,”
Advocates may not agree on every solution, but I want to credit Lauren Rettagliata and Teresa Pasquini, who write on their Housing That Heals project, “Housing That Heals is more than a house, a program, or a room key. It is a system of care that wraps a person in all of the necessary medical, clinical, rehabilitative, and social supports they need to live and die in dignity.” They argue California must move beyond rigid “fail-first” or “housing-first” approaches and instead create a full continuum—from crisis to acute, sub-acute, and supported housing—so everyone can recover and participate in the community.
But these common-sense and holistic solutions remain distant to lawmakers. CARE Court is not meeting the 7,000–12,000 people it was claimed to prioritize, SB 43 is rushed toward implementation before counties are ready, and policy has continued to push coercive care and locked facilities for mental health crises over a more balanced approach. The answer is clear: slow down, prioritize lived expertise, and respect those we promised to support. Uphold evidence-based levels outlined in the LOCUS framework—often overlooked but vital for real recovery. Reform must be rooted in evidence, compassion, and the wisdom of peers, moving California toward choice, dignity, and authentic recovery for all.
This isn’t an argument about coercion—it’s about making sure people can access the kinds of services they truly want and stopping those consistently rejected. People aren’t refusing all support, just the kinds of care currently offered by counties—care that too often misses the mark. And if you’ve ever stepped foot in some of these facilities, ask yourself—do you blame them?
Vanessa Ramos is a Senior Advisor at Disability Rights California and a member of the All People’s Health Collective, advancing disability justice and equitable drug policy through community advocacy and peer leadership. Outside of work she’s mom to Angel, Esther, Little Kitty, and Sol.