Senate Bill 43 was supposed to save lives. With thousands of people cycling through San Francisco emergency rooms and jails and taking up residence on sidewalks, the law made it easier to compel treatment for individuals too sick to care for themselves by expanding the criteria to become a ward of the city. Gov. Gavin Newsom called it a “major overhaul of our mental health system.”
But newly released reports show that the promised transformation has not materialized.
While the rules of mental health administration have changed dramatically, there was no infusion of the resources necessary to deliver on those 2023 hopes: not enough money, beds, or conservators to oversee the cases of those desperately needing help.
With the system already overloaded, the law effectively changed little. San Francisco budgets for 18 deputy conservator positions, but five are vacant—leaving staff responsible for upwards of 60 conservatees at a time, according to the Human Services Agency.
In a somber hearing in late June at City Hall, officials acknowledged the apparent failure of SB 43 reforms in San Francisco.
“It is profoundly disappointing that we are where we are,” said Supervisor Rafael Mandelman, who convened the hearing.
For decades, conservatorships could be imposed only when a person could not meet their basic needs due to mental illness or chronic alcoholism. SB 43 expanded the law to include severe substance use.
In San Francisco, where a state of emergency was declared over drug overdoses in 2021, city leaders heralded the law as a solution.
But since SB 43 took effect, San Francisco has not initiated a single conservatorship based solely on the expanded criteria of substance use disorders.
As part of the rollout, the city created a running list of people who might qualify for conservatorship. To date, 369 names have been floated, but only 44 of those have been conserved, and 30 others currently appear on the list.
The city’s conservators oversee about 691 people each month, just 3% more than in 2023, according to Kelly Dearman, executive director of the Department of Disability and Aging Services.
“It hasn’t been the big magical pill that we had hoped for,” Dearman conceded in the hearing.
It is just the latest dilemma in California mental health policy since the Lanterman-Petris-Short Act of 1967 ended the era of indefinite institutionalization in state psychiatric hospitals. The LPS Act created a specific type of conservatorship that must be renewed before a judge each year. Conservatees are essentially wards of the city, with an assigned public conservator responsible for their housing, medical, and personal decisions.
Despite its extensive authority, California’s LPS conservatorship system has operated with little accountability or oversight. A long-overdue state audit in 2019 found that counties routinely failed to track whether conserved individuals actually received treatment or if their conservatorships led to meaningful outcomes.
'It’s like fixing a bullet wound with a Band-Aid.'
Keris Jän Myrick, vice chair of Disability Rights California
In San Francisco, a 2022 audit was blunt: The city had no system to measure whether conservatorships work, no coordinated plan to oversee care, and no data showing that people conserved under the LPS Act saw improvement.
Nonetheless, the city doubled down on expanding conservatorship. San Francisco and San Luis Obispo County were the only California counties to implement SB 43 as soon as possible, in January 2024; others chose to wait until closer to the deadline in 2026. Newsom celebrated San Francisco’s early adoption as an example for the rest of the state.
Ahead of implementation, city departments trained around 1,700 staffers and clinicians, and materials were distributed to hospitals.
But the implementation of new rules and processes did not come with the resources necessary to provide care — just as the original LPS Act intended for municipalities to take over mental healthcare but didn’t provide the funding needed to do so.
“It does no one any good if we conserve somebody and have no care lined up,” said Dr. Daniel Tsai, director of the SF Department of Public Health. “They’re still on the street, not getting care. It’ll look nice on a chart for an upward line, but it won’t actually solve the outcome we’re looking for.”
Keris Jän Myrick, vice chair of Disability Rights California, said “it’s like fixing a bullet wound with a Band-Aid.”
“If there are no services and supports there — which they weren’t there before — they certainly aren’t going to be there now,” she added.
Aaron Meyer, chair of the governmental affairs committee for the California State Association of Psychiatrists, said San Francisco’s struggle to implement the law reflects a statewide lack of planning. The legal change did not come with consistent guidance. There is no model referral form, standard, list of best practices, or oversight at the state level. But most of all, there is not enough state funding for the complex residential treatment centers many conservatees require.
'We are a bad parent if we are taking away someone’s autonomy and then placing them into a placement that is highly likely to have them going out and engaging in the same behaviors that may well get them dead.'
Supervisor Rafael Mandelman
“If you don’t have an actionable placement for people with standalone severe substance use disorder, you may not be considered for a conservatorship,” Meyer said.
Today, San Francisco has about 100 locked subacute treatment beds and rents another 48 from facilities as far away as Southern California. Funding has been approved for approximately 90 more beds at Zuckerberg General Hospital.
In June, Mayor Daniel Lurie and public health officials announced plans to add 73 beds over the next year, including 20 locked placements for conservatees. According to Kelly Kirkpatrick, director of administration and operations at Mental Health SF, 100 new beds would cost about $20 million a year to maintain.
“Even if we were to, tomorrow, conserve 800 people, without the actual beds and capacity, we will not be able to actually provide the care,” Tsai said.
“It’s not a need that San Francisco is ever going to be able to meet on our own,” added Mandelman.
In the meantime, some conservatees are being placed in shelters or tiny homes with intensive wraparound services. Tsai described the approach as a pilot, but Mandelman questioned whether it is appropriate — or safe.
“When we conserve someone, we are saying this is a person who needs a parent,” he said. “We are a bad parent if we are taking away someone’s autonomy and then placing them into a placement that is highly likely to have them going out and engaging in the same behaviors that may well get them dead.”