The 2019-20 Budget: Analysis of the Governor’s Mental Health Workforce Proposal

The 2019-20 Budget: Analysis of the Governor’s Mental Health Workforce Proposal GABRIEL PETEK LEGISLATIVE ANALYST MAY 2019 Summary Governor Proposes $50 Million in One-Time General Fund for Mental Health Workforce. To ameliorate what the Governor considers to be statewide and regional shortages of mental health professionals, the Governor has proposed a $50 million one-time General Fund augmentation for existing state programs that provide scholarships and student loan repayment for mental health professionals who agree to work in underserved areas. This brief analyzes the Governor’s proposal. Mixed Evidence of Statewide Mental Health Workforce Shortages . . . First, we provide basic background on mental health services delivery, funding, and workforce. Following our preliminary review, we find mixed evidence of a statewide shortage for mental health professionals overall. While certain mental health workforce projections show the state is likely to experience a shortage, other evidence we reviewed does not suggest this to be the case. That said, we find stronger evidence that the state could be experiencing a shortage of psychiatrists. . . . But Regional Disparities in the Supply of Mental Health Professionals Exist. While the evidence is mixed regarding the presence of a statewide mental health workforce shortage, the evidence is strong that significant regional disparities exist in the supply of mental health professionals. Notably, regions such as the Inland Empire and the San Joaquin Valley have significantly fewer mental health professionals per capita than the state as a whole. Options for Legislative Consideration. We provide several options for the Legislature to consider as it decides whether to approve the Governor’s proposal. The first option is to take pause and identify the state’s most critical mental health workforce needs and the most cost-effective strategies for ameliorating them. Exercising this first option would involve delaying funding until many of the outstanding uncertainties related to the state’s mental health workforce strategies are better understood. The second option is to approve the Governor’s proposal, but add parameters to ensure the funding is targeted toward the areas of greatest need. The third option is to provide funding but through approaches that differ from the Governor’s. Examples of alternative approaches include (1) funding programs that more specifically support the education and training of new mental health professionals—such as funding new psychiatry residency slots—or (2) giving counties flexible funding for the delivery of mental health services. analysis full gutter 2019-20 BUDGET INTRODUCTION a major role in the funding and delivery of public mental health services. In particular, counties are The Governor proposes a $50 million one-time generally responsible for arranging and paying for General Fund augmentation for existing mental community mental health services for low-income health workforce programs that are administered individuals with the highest mental health needs. by the Office of Statewide Health Planning and Counties deliver these services through a mix Development (OSHPD). This brief (1) provides of county mental health staff and contracted background on the state’s mental health workforce, providers. In 2018-19, counties are receiving (2) gives an overview of existing programs and $9.3 billion in funding for community mental health funding aimed at improving the state’s mental services. About half of funding for county mental health workforce, (3) summarizes and assesses the health services is provided through block grants Governor’s proposal, and (4) provides options for that grow on an annual basis in line with state tax legislative consideration. revenues. Federal Medicaid funding makes up most of the remaining funding. BACKGROUND Recent Policy Changes Have Likely Led to an Increase in Demand for Mental Health Services In this section, we provide a brief overview and Providers. Demand for community mental of public community mental health services health services has very likely increased over the delivery and funding in California. We then provide last several years, in large part due to the federal background on the various professions that provide Patient Protection and Affordable Care Act (ACA), mental health services. Finally, we briefly summarize implemented in 2014. Under the ACA, California the history of mental health workforce funding in has experienced significant increases in the number the state. of residents with health insurance, which has Community Mental Health Services likely increased state residents’ willingness and capacity to seek mental health services. Funding Defining Community Mental Health. Mental for public community mental health services has health services include the diagnosis and treatment also increased in recent years. Since the ACA for individuals experiencing mental illness. Common was implemented, total annual funding for county mental health diagnoses include depression mental health services has increased by 71 percent, and schizophrenia. Common treatments include from $5.5 billion to $9.3 billion. therapy, crisis intervention and stabilization, medication, and inpatient psychiatric services. Mental Health Professions As used in this report, “community mental health A Variety of Professions Provide Mental services” generally comprise all mental health Health Services. In an effort to ensure quality care, services delivered in community settings, thereby state laws restrict the delivery of mental health excluding those delivered in certain other settings, services to licensed providers. Such licensure notably correctional settings. Community mental requirements generally impose minimum education health services are commonly paid for by both and work-experience standards for providers to private and public health insurance. According to be allowed to practice independent of supervision. 2015 national estimates, private sources—such State law permits a variety of professions to deliver as commercial health insurance—paid for about mental health services and establishes scope of one-third of mental health services. Medicaid practice rules for which types of services different accounts for another one-third of spending and professions may provide. For example, psychiatrists Medicare and other public sources comprise the may prescribe medicine and provide a variety of remaining one-third. diagnostic and therapeutic services. Psychologists, In California, Public Community Mental Health by contrast, may not prescribe medicine but may Services Are Primarily Delivered and Funded provide a similar array of diagnostic and therapeutic Through Counties. In California, counties play services as psychiatrists. Figure 1 summarizes 2 LEGISLATIVE ANALYST’S OFFICE analysis full gutter 2019-20 BUDGET the professions specializing in the Figure 1 delivery of mental health services. A Variety of Professions Specialize in the Delivery of Existing Mental Health Mental Health Services Workforce Programs Profession Education Requirement State Administers a Variety Can Prescribe Medication of Mental Health Workforce Psychiatrist Medical degree Programs. Since even before Psychiatric nurse practitioner Master’s or doctorate the ACA, state policymakers Cannot Prescribe Medication have had concerns about the Psychologist Professional doctorate capacity of the state’s mental Clinical counselor Master’s health workforce to meet demand Clinical social worker Master’s Marriage and family therapist Master’s for services. To address these Psychiatric mental health registered nurse Master’s concerns, the state and counties Psychiatric technician High school diploma administer a variety of programs aimed at improving the overall dedicates the revenue to mental health services. supply, geographic distribution, and diversity A total of $445 million in MHSA revenues from the of the state’s mental health workforce. Often, act’s initial years was set aside on a limited-term these existing programs offer (1) scholarships basis to fund state and county workforce initiatives. or stipends (as high as $25,000) for prospective Roughly half of this funding was administered at mental health professionals still completing their the state level (most recently, by OSHPD), with the education or (2) student loan repayment (as other half going directly to counties to administer. high as $105,000) for practicing mental health The state and counties had through 2017-18 to professionals. In general, these existing programs spend this $445 million. To continue funding into are designed to support the workforce needs of the 2018-19, the Legislature appropriated $11 million public community mental health system as well as in one-time MHSA funding for state mental health some types of private providers that largely serve workforce programs. low-income populations. These existing programs OSHPD Is Responsible for Creating include service obligations where recipients must Five-Year Mental Health Workforce Plans. In work at an eligible location for a specified period addition to operating mental health workforce of time—typically one-to-two years—or otherwise programs, OSHPD is responsible for developing repay the scholarship, stipend, or loan repayment five-year plans outlining strategies to meet the assistance. Eligible locations include practice sites state’s mental health workforce education and located in designated shortage areas as well as training needs. OSHPD’s most recent five-year certain safety-net clinics that serve low-income plan was released in early 2019. Historically, the and other high-need populations, regardless of MHSA funding described in the previous paragraph whether they are located in designated shortage supported the funding priorities outlined in the areas. Other existing state programs are aimed five-year plans. Given the expiration of the MHSA at improving educational and training capacity. funding in 2017-18, there is no longer funding These programs, for example, provide funding specifically dedicated to supporting the 2019 for residency programs or clinical rotations—a five-year plan. necessary component in the training of at least certain mental health professionals. Counties Free to Dedicate up to 15 Percent of MHSA Revenue to Local Workforce Funding Specifically Dedicated to State Programs. The MHSA authorizes, but does not Mental Health Workforce Programs Largely require, counties to spend a portion of their MHSA Expired in 2017-18. The Mental Health Services revenues on workforce development activities. The Act (MHSA), approved by voters in 2004, places maximum amount of MHSA revenues that counties a 1 percent surtax on incomes over $1 million and www.lao.ca.gov 3 analysis full gutter 2019-20 BUDGET can spend on workforce development activities Mixed Evidence of Statewide Mental is around 15 percent of total MHSA revenues, Health Workforce Shortages though we would note that this 15 percent ceiling Projections From Academic Researchers includes the total funding counties may dedicate to Predict the State Could Face a Shortage of certain other purposes as well—namely to capital Mental Health Professionals. Researchers at the and technology acquisition and development University of California, San Francisco (UCSF) project and prudent reserves. Were counties to devote that, unless the total number of people entering one-third of allowable MHSA funding to workforce mental health professions in the state increases, programs, for example, almost $100 million California would face a shortage of mental health annually in MHSA funding could be used. It is our professionals between 2016 and 2028. If the total understanding that counties have not generally number of people entering mental health professions chosen to devote significant MHSA funding to local does not increase, these projections show that mental health workforce development. In large the supply of mental health professionals could fall part, this is likely due to the fact that the MHSA short of demand for mental health professionals by specifically dedicated a significant portion of MHSA between 12 percent and 40 percent by 2028. As we revenues from the act’s early years to workforce describe below, the state has recently experienced development. growth in the number of masters- and doctoral-level professional mental health graduates. (Professional GOVERNOR’S PROPOSAL mental health graduates generally include those $50 Million One-Time General Fund to intending to pursue careers in clinical care as Improve Mental Health Workforce. The opposed to research.) Governor’s budget proposes $50 million in one-time General Figure 2 Fund for existing state mental A Variety of Mental Health Professionals Would health workforce programs Receive Support Under the Governor’s Proposal administered by OSHPD. Figure 2 lists the mental health Student Loan Repaymenta Scholarshipb professions that the funding would support. The funding would be Clinical counselor  available through 2025-26. The Clinical social worker   funding is intended to ameliorate Community health worker/ promotora   what the Governor considers to be Consumer/ peer counselor  statewide and regional shortages Marriage and family therapist  of mental health professionals. Medical assistant   Mental health administrative staff  ASSESSMENT Physician assistant   In this section, we provide our Psychiatric mental health registered nurse   assessment of the magnitude and Psychiatric nurse practitioner   geographic distribution of potential Psychiatrist  mental health workforce shortages Psychologist  and the likely impact of the Rehabilitation counselor  Governor’s proposal in ameliorating a Student loan repayment programs that would receive funding under the Governor’s proposal these potential shortages. include the Advanced Practice Healthcare Loan Repayment Program, Allied Healthcare Loan Repayment Program, Licensed Mental Health Services Provider Education Program, Mental Health Loan Assumption Program, State Loan Repayment Program, and Steven M. Thompson Physician Corps Loan Repayment Program. b Scholarship programs that would receive funding under the Governor’s proposal include the Allied Healthcare Scholarship Program and Advanced Practice Healthcare Scholarship Program. 4 LEGISLATIVE ANALYST’S OFFICE analysis full gutter 2019-20 BUDGET Recent Growth in Professional Mental Health what we would expect under a shortage. Moreover, Graduates Brings Uncertainty to Whether the over this same time period, the number of mental State Is Facing a Shortage. To see whether health professionals has increased by about the number of people entering mental health 50 percent. Figure 4 (see next page) displays professions has in fact remained constant in recent these trends for mental health professionals years (which would suggest that the education compared to all occupations. These trends overall and training of new mental health professionals do not suggest that the state is facing a statewide is likely not meeting the state’s workforce needs), shortage of mental health professionals. we reviewed data on the number of individuals Stronger Evidence of Inadequate Supply of graduating with professional masters or doctoral Psychiatrists Statewide. Evidence from a variety degrees in mental health-related fields from of sources suggest that California may currently or California universities. As shown in Figure 3, in the near future face a shortage of psychiatrists. from 2009-10 to 2016-17, the annual number UCSF researchers found that a significant number of professional degree graduates in the fields of of psychiatrists are nearing retirement age. In clinical psychology, social work, counseling, and addition, Bureau of Labor Statistics data do not psychiatric nursing increased from 4,700 to around show an increase in the number of psychiatrists 8,000—a 70 percent increase. (Over this same time in the state between 2010 and 2018. At the same period, California’s resident population increased by time, average psychiatrists’ salaries appear to about 6 percent.) If sustained, this increase in the have increased to a much greater degree than number of graduates may, but is not guaranteed all occupations throughout California, suggesting to, significantly ameliorate the projected mental there could be significant competition for a health workforce shortage that does not necessarily potentially limited number of psychiatrists in the assume an increase. More than 80 percent of the state. We would note that non-psychiatrists, such increase in professional mental health graduates as psychologists and psychiatric technicians, is from graduates of private universities in the state, which do Figure 3 not rely on augmentations in state funding to grow enrollment. Annual Number of Graduates With Professional Mental Health Degrees Has Grown Significantly Moderate Salary Growth for Mental Health Professionals Cumulative Percent Change in Professional Mental Health Masters- and Doctoral-Level Graduates Does Not Suggest There Is a Statewide Shortage. In addition, 80% we would expect that a shortage of mental health professionals 70 California Mental Health Graduates might lead to sharply rising 60 salaries for mental health professionals as hospitals, clinics, 50 counties, and other organizations 40 compete to fill needed mental health positions. We reviewed 30 U.S. Mental Health Graduates data from the Bureau of Labor Statistics, which showed that 20 between 2010 and 2018 mental 10 California Population health professionals’ average salaries have increased in 2009-10 2016-17 California at about the same rate as all occupations throughout the California economy, contrary to www.lao.ca.gov 5 analysis full gutter 2019-20 BUDGET Figure 4 Strong Employment Growth and Moderate Salary Growth For Most Mental Health Professionalsa, b Cumulative Percent Change in Total Employment and Average Salaries Total Employment Average Salary 60% 20% Mental Health All Occupations Professionals 45 15 Mental Health Professionals 30 10 All Occupations 15 5 2010 2018 2010 2018 a Among mental health professionals, psychatrists represent an exception to these trends. Pyschiatrists have likely experienced sharply increasing average salaries. Data limitations prevent us from drawing conclusions on the growth in the psychiatry workforce. b Mental health professionals includes clinical, counseling, and school psychologists; marriage and family therapists; mental health and substance abuse social workers; psychiatrists; psychiatric aides; psychiatric technicians; and substance abuse, behavioral disorder, and mental health counselors. can perform some of the same diagnosis-related distributed across the state. Figure 5 shows and therapeutic tasks as psychiatrists. As certain regions have a high number of overall such, hospitals, clinics, counties, and other mental health professionals per 100,000 residents organizations can utilize non-psychiatrists in place relative to the state average. For example, the of psychiatrists. However, other than psychiatric Greater Bay Area has almost 50 percent more nurse practitioners (whose statewide employment mental health professionals on a population basis numbers and salaries we were not able to obtain than the statewide average. Other regions, such data to evaluate), psychiatrists are one of the as Los Angeles and the Sacramento area, have only specialized mental health professionals comparable numbers of mental health professionals whose scope of practice allows them to prescribe to the statewide average. Certain regions, medication. Accordingly, psychiatrists play a however, have very low numbers of mental health critical role in the mental health services delivery professionals. The Inland Empire and San Joaquin continuum. Valley regions have about two-thirds as many mental health professionals on a population basis Regional Disparities Exist in the as the statewide average, or about half as many Mental Health Workforce mental health professionals on a population basis as the Greater Bay Area. Regional Disparities Exist Among Mental Distribution of Psychiatrists Throughout Health Professionals Overall. Although we find the State Is Particularly Disparate. Regional mixed evidence of a statewide shortage of most disparities of psychiatrists are greater than for mental health providers, we do find strong evidence mental health professionals overall. While the that mental health professionals are unequally 6 LEGISLATIVE ANALYST’S OFFICE analysis full gutter 2019-20 BUDGET Greater Bay Area has 70 percent more psychiatrists each of which supports different sets of mental than the statewide average, the Inland Empire and health professionals. For example, funding the San Joaquin Valley have only about 50 percent of Steven M. Thompson Program would support the statewide average on a population basis. only psychiatrists while funding for the Mental Unclear to What Extent Regional Disparities Health Loan Assumption Program would support Reflect Differences in Demand for Mental Health a broad range of professionals from clinical social Services. While there is strong evidence of regional workers to psychiatric nurse practitioners. The disparities in terms of the supply administration has shared that while OSHPD is of mental health professionals, it Figure 5 is unclear to what extent different regions have different demand or Mental Health Professionals Are needs for mental health services. Unequally Distributed Across the State For example, the population of Number of Providers Per 100,000 Area Residents the Greater Bay Area may desire or need more mental health All Mental Health Professionals services than the population of Greater Bay Area San Diego. Accordingly, while the Central Coast disparities in the supply of mental health professionals suggest some California regions may be experiencing Los Angeles relatively more acute workforce Sacramento Area shortages, additional analysis is needed to determine which regions Orange are facing workforce challenges San Diego Area relative to the demand or need for Northern and Sierra mental health services. San Joaquin Valley Potential Impact of Inland Empire Funding Under the 50 100 150 200 250 300 350 Governor’s Proposal Is Uncertain Psychiatrists Detail Lacking on How Greater Bay Area Governor’s Proposed Funding Central Coast Would Be Allocated. Key details are missing on how the California $50 million in one-time General Los Angeles Fund proposed by the Governor Sacramento Area would be allocated among existing mental health workforce programs. Orange For example, the administration San Diego Area has not released a plan for how Northern and Sierra the funding would be allocated among scholarship and student San Joaquin Valley loan repayment programs. In Inland Empire addition, it remains unclear how 5 10 15 20 25 30 much funding would be allocated to the different state programs, Source: Janet Coffman et al., California’s Current and Future Behavioral Health Workforce. www.lao.ca.gov 7 analysis full gutter 2019-20 BUDGET evaluating various potential allocation strategies, it workforce programs may have had some positive is not certain whether a detailed allocation proposal impact in increasing the overall number of mental will be released at the time of the May Revision. health professionals throughout the state. However, Governor’s Proposal Is Not Linked to a in the time available to perform this analysis, Long-Term Mental Health Workforce Plan. As we were unable to perform a comprehensive previously noted, earlier this year, OSHPD released evaluation of the impact that existing state a five-year plan outlining the state’s vision and mental health workforce programs have had on strategies for improving the state’s mental health the overall supply and distribution of the state’s workforce. Unlike previous plans, the five-year plan mental health workforce. It is our understanding did not specifically come with any attached funding. that OSHPD, which oversees the mental health The $50 million proposed by the Governor, while workforce issues and programs, has not released in many ways consistent with both the current and a comprehensive analysis of the programs’ impact. previous five-year mental health workforce plans, is We did, however, review data on where recipients not explicitly tied to the long-term plan. According of mental health workforce stipends or student loan to the administration, the reason the plan and the repayments worked after their service obligations funding are not more closely linked largely relates had expired. As Figure 6 shows, this data showed to the plan being released after the Governor’s little relationship between the regions of the state budget. In addition, in our view, OSHPD’s plan does experiencing the greatest workforce challenges and not contain sufficient detail to be used specifically the work location of award recipients following the as a funding plan. For example, the plan does not completion of their service obligations. identify which regions and which mental health professions are experiencing the most acute mental health workforce needs. Rather, it lays out the general vision Figure 6 and goals of the administration Regions With the Smallest Mental Health Workforces as it pertains to mental health Have Not Seen the Largest Workforce Gains Under workforce. OSHPD’s Programs Certain Existing State Rank Programs Would Not Receive Funding Under the Governor’s Region With the Smallest Mental Region With the Most Proposal. Not all existing mental Region Health Workforcesa Award Recipientsb health workforce programs would receive an augmentation Inland Empire 1 8 under the Governor’s proposal. San Joaquin Valley 2 5 Northern and Sierra 3 1 Primarily, the Governor’s proposal San Diego Area 4 6 excludes existing programs, also Orange 5 7 administered by OSHPD, aimed at Sacramento Area 6 4 improving the state’s educational Los Angeles 7 3 and training capacity for mental Central Coast 8 2 health professionals, such as those Greater Bay Area 9 9 that support residency programs a Numbers reflect the ranking of regions in terms of the size of their mental health workforces, controlling for their population sizes. A ranking of 1 applies to the region with the smallest mental and clinical rotations. health workforce and a ranking of 9 applies to the region with the largest mental health workforce. b Uncertainty Around Whether Numbers reflect the ranking of regions in terms of where beneficiaries of OSHPD mental health workforce, education, and training programs practice following the completion of their service Existing State Programs and obligations (controlling for the regions’ population sizes). A ranking of 1 applies to the region Strategies Have Been Effective. where the most awardees practice and a ranking of 9 applies to the region where the fewest awardees practice. Overall, existing state mental health OSHPD = Office of Statewide Health Planning and Development. 8 LEGISLATIVE ANALYST’S OFFICE analysis full gutter 2019-20 BUDGET OPTIONS FOR THE LEGISLATURE Approve Funding, but Establish Parameters for How Funding Is In this section, we provide several options for Allocated legislative consideration related to the Governor’s proposed $50 million in one-time General Fund for Under the Governor’s proposal, the mental health workforce: (1) take pause and study administration would have significant discretion to the underlying workforce issues further before allocate the funding among existing state OSHPD appropriating funding, (2) adopt the Governor’s programs and, in turn, for example, how much proposal with parameters designed to improve financial support different professions would effectiveness, and (3) adopt the Governor’s receive. Provided the Legislature wishes to provide proposed level of funding in 2019-20 but allocate funding for existing mental health scholarship and the funds adopting an alternative approach. We student loan repayment programs administered describe these options further below. by OSHPD, the Legislature could consider what parameters it would like to set for the appropriation. Take Pause to Identify Workforce The following bullets provide parameters that Needs and Cost-Effectiveness of the Legislature might consider including in Strategies budget-related language: Identify Workforce Needs and Strategies • Prioritize Regions With Most Acute Before Providing New State Funding. We have a Shortages. As previously noted, our number of outstanding questions related to (1) the preliminary analysis has revealed that certain magnitude, geography, and causes of any current regions of the state—most notably the Inland or future mental health workforce shortages and Empire and the San Joaquin Valley—are (2) the effectiveness and associated trade-offs of likely experiencing the most acute shortages. alternative policy solutions to addressing potential Nevertheless, existing mental health workforce mental health workforce shortages. For example, programs at OSHPD have not necessarily an important, open question that our analysis proven effective in increasing the workforce in was unable answer is what impact psychiatric these potentially high-need regions. To ensure health nurses and nurse practitioners have in this funding goes to the areas with the highest mitigating potential mental health workforce need, the Legislature might consider directing shortages throughout the state. Given this and OSHPD to prioritize regions with acute other outstanding questions and uncertainties, the shortages in future funding rounds. Legislature could reject the Governor’s proposed • Target Funding Toward Prescribing funding and instead direct OSHPD or another Professions. As discussed earlier, our qualified entity to study the state’s mental health preliminary analysis suggests potentially workforce and recommend policy solutions to greater shortages among psychiatrists ameliorate any identified issues. compared to non-psychiatrist mental health In Meantime, Counties Can Use Local MHSA professionals. As such, the Legislature might Funding to Meet Local Workforce Needs. To the consider dedicating a significant portion extent that counties wish to dedicate funding to of the $50 million in funding to programs mental health workforce programs, they could use targeting the recruitment of psychiatrists. The a portion of their local MHSA funding to support Legislature could also consider targeting the local mental health workforce programs. We would funding toward psychiatric nurse practitioners note that until 2018-19, most funding for mental since, given their ability to prescribe health workforce comprised local MHSA funding medication, they can also provide a key redirected by the state to mental health workforce specialized service delivered by psychiatrists. programs. • Extend Service Obligations. As previously noted, existing state mental health workforce programs generally require one-to-two year www.lao.ca.gov 9 analysis full gutter 2019-20 BUDGET service obligations by awardees in designated • Flexible Funding for Counties Facing shortage areas and other specified locations. Workforce Challenges. The Legislature could Anecdotally, we have heard that awardees consider redirecting the Governor’s proposed sometimes fulfill their service obligations $50 million to instead provide flexible funding and soon thereafter move to other practice to counties facing workforce challenges, locations and/or private practice to earn which counties could use in accordance with higher pay. To slow the rate of exit from the local needs and conditions. For example, public mental health system as well as from rather than or in addition to scholarships high-need regions of the state, the Legislature or student loan repayment, counties could could consider extending awardees’ service choose to use such funding to support local obligation requirements beyond one-to-two education and training programs or to improve years. pay in areas that are facing acute recruiting • Ensure Against Awarding Transfers From challenges. Under this approach, the funding High-Need Regions. Currently, awardees could be directed to counties in regions may have previously worked in one county potentially facing the most acute mental health facing a mental health workforce shortage and workforce issues. moved to work in another—and be eligible for • Expand the Mental Health Workforce an award. In such a case, the award would Pipeline. While scholarship and student help to change which county is facing a loan repayment programs may have some workforce challenge but not relieve the state’s positive impact in growing the overall workforce issue as a whole. The Legislature supply of mental health professionals, they might consider restricting eligibility for awards potentially are most effective in determining to individuals moving from out-of-state or the regional distribution and practice location from regions of the state facing less severe of new professionals. Other approaches shortages. aimed at improving educational capacity may be relatively more effective in increasing Provide Funding, but the overall supply of mental professionals throughout the state. Given our analysis of Adopt Alternative Approach existing workforce issues, we recommend Several Different Options Available to the Legislature consider prioritizing any Legislature. The Legislature could also consider pipeline augmentations for psychiatrists and alternative approaches to that of the Governor, psychiatric nurse practitioner programs. whose proposal would largely utilize scholarships Examples of potential interventions include and student loan repayment strategies to improve funding for psychiatric residency programs the mental health workforce. Potential alternative and psychiatric nurse practitioner clinical approaches include: rotation programs. LAO PUBLICATIONS This report was prepared by Ben Johnson and reviewed by Mark C. Newton. The Legislative Analyst’s Office (LAO) is a nonpartisan office that provides fiscal and policy information and advice to the Legislature. To request publications call (916) 445-4656. This report and others, as well as an e-mail subscription service, are available on the LAO’s website at www.lao.ca.gov. The LAO is located at 925 L Street, Suite 1000, Sacramento, CA 95814. 10 LEGISLATIVE ANALYST’S OFFICE