Forced Treatment Hasn’t Flooded Hospital Emergency Rooms - Yet | Voice of San Diego

Treatment room during a hospital tour at Kaiser Permanente 
San Marcos Medical Center on Aug. 4, 2023. / Photo by Ariana Drehsler

SB 43's Unexpected Impact: San Diego County's Forced Treatment Law Fails to Flood Emergency Rooms as Predicted

Involuntary holds decrease despite expansion of conservatorship criteria, surprising officials and advocates alike

SAN DIEGO — Seven months after San Diego County implemented California's Senate Bill 43, expanding criteria for involuntary mental health holds and conservatorships, the feared flood of patients overwhelming hospital emergency rooms has yet to materialize. Instead, data shows a surprising decrease in involuntary holds, confounding expectations and raising questions about the law's effectiveness.

County data reveals that involuntary 72-hour holds — commonly known as 5150 holds — actually dropped in the first three months of 2025 compared to the prior three quarters of 2024. Temporary and longer-term conservatorships also showed a downward trend, despite expanded criteria that now includes people with severe substance use disorders who cannot provide for their personal safety or medical care.

"The fear we had that there was going to be this huge increase just really hasn't materialized," said Steve Koh, chief of clinical psychiatry at UC San Diego Health.

A Controversial Implementation

The implementation of SB 43 in San Diego County was marked by significant controversy and preparation delays. Governor Gavin Newsom signed the legislation on October 10, 2023, marking the most significant update to California's civil detention and conservatorship laws in more than 50 years. The law expanded the definition of "gravely disabled" to include people with severe substance use disorders or co-occurring mental health disorders who cannot provide for their basic personal needs, safety, or medical care.

Most counties in California decided to start applying SB-43 in January 2026. However, San Diego County chose to implement the law on January 1, 2025, after initially considering a one-year delay following pressure from local hospitals.

In December 2023, county supervisors voted 3-2 to delay implementation for one year, citing concerns about overwhelming emergency departments already operating at or over capacity. Local hospitals pushed hard for a deferment, noting that their emergency departments often operate at or over capacity and could be additionally clogged by broadening the criteria.

Hospital Concerns and Preparation Efforts

The Hospital Association of San Diego & Imperial Counties had warned that the expansion would significantly increase involuntary holds brought to emergency departments without adding necessary capacity or resources. Chris Van Gorder, CEO of Scripps Health, had stated that implementing the law without proper preparation "would be a disaster for the hospitals as we don't have the capacity to board even more patients than we do now."

In response to these concerns, San Diego County spent the year preparing extensively. Officers from law enforcement agencies representing all 18 cities and the County Sheriff's Office have gone through SB-43 trainings. The trainings have been led by the Jewish Family Service Patient Advocacy program.

County Behavioral Health Services estimated an increase of approximately 1,500 additional 72-hour detentions annually under the new law. However, the actual implementation has produced markedly different results.

Unexpected Results and Explanations

The county's contracted crisis stabilization units, prepared to handle an influx of patients who might otherwise flood hospitals, also haven't experienced the expected surge in demand despite efforts to redirect patients there.

Several factors may explain the disconnect between predictions and reality:

Limited Understanding of New Criteria: Koh and others said some clinicians and police officers have been unclear on whether patients meet the new criteria, leaving some to stick with longstanding protocols rather than use new ones under SB 43.

Resource Constraints: Despite preparation efforts, there remains broad agreement that insufficient resources exist for post-hospital treatment options. Post-hospital placements for patients on temporary holds and longer-term conservatorships remain hard to come by, Koh said, and clinicians can be reluctant to take away patients' rights to choose their own treatment path without a clear end game.

System Limitations: Michelle Routhieaux, who leads San Diego's Depression and Bipolar Support Alliance, noted that even patients who want hospital care have historically struggled to access it in San Diego County. "Either there's no space for them or the hospital says, 'You don't meet criteria,'" she said.

Ongoing Challenges and Future Outlook

County officials remain cautious about drawing definitive conclusions from the early data. "While the county has recently observed decreases in holds and fluctuations in permanent conservatorships, it is still early to clearly understand the impacts of the SB 43 legislation," county spokesperson Tim McClain wrote in an email.

The county memo suggests involuntary holds could increase over time as providers become more familiar with the revised criteria and adapt their practices accordingly. Additionally, upcoming state updates on insurance reimbursements could increase demand for local inpatient substance use disorder treatment.

Stakeholder Perspectives

Mental health advocates remain divided on the law's implementation and early results:

Linda Mimms, a longtime mental health advocate who supported SB 43, expressed frustration but not surprise at the limited impact. She believes more education is needed on the law and that local agencies need to supply necessary services to support people who could be connected to treatment under the expanded criteria.

Cathryn Nacario, CEO of National Alliance on Mental Illness of San Diego, emphasized that infrastructure still needs development: "We still have some infrastructure that needs to be brought online to really support and place people in appropriate facilities and programs."

The Hospital Association of San Diego & Imperial Counties, which had advocated for delaying implementation, declined to comment on the story.

Political Context and Criticism

The delay in implementation and subsequent limited impact has drawn criticism from various officials. San Diego Mayor Todd Gloria, who supported immediate implementation, had argued that city first responders spent over 130,000 hours responding to more than 53,000 behavioral health-related emergency calls annually, with many individuals cycling between streets, emergency rooms, and jails.

Supervisor Terra Lawson-Remer, who opposed the delay, had argued for moving forward as quickly as possible to help those in need, drawing comparisons to the region's rapid response during the COVID-19 emergency.

Comparing Experiences Across Major County Systems

San Diego's experience with SB 43 contrasts sharply with other large county medical systems that have implemented the law, revealing varying impacts across California.

San Francisco's Mixed Results: San Francisco, which implemented SB 43 alongside San Diego in January 2024 (with San Luis Obispo), has experienced different challenges despite similar resource constraints. Since SB 43 took effect, San Francisco has not initiated a single conservatorship based solely on the expanded criteria of substance use disorders, according to recent reports.

The city created a running list of 369 people who might qualify for conservatorship under the expanded criteria, but only 44 have been conserved, with 30 others currently on the active list. San Francisco'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.

Dr. Maria Raven, an emergency physician at UCSF, has been particularly vocal about the law's limitations. In a March 2024 op-ed, she wrote that "our emergency department and others like it across the region are overwhelmed" and criticized SB 43's fundamental approach, noting that "substances wear off. And when they do, most patients don't demonstrate the type of cognitive damage that would require me to continue an involuntary hold".

Los Angeles County's Delayed Approach: Los Angeles County, California's most populous county, chose to delay implementation until 2026, citing concerns about overwhelming their already strained system. The county's decision reflects similar concerns raised by San Diego's hospitals about emergency department capacity.

Santa Clara County's Accelerated Timeline: In contrast to the delays, Santa Clara County moved to implement SB 43 on an accelerated timeline despite significant financial challenges. The county faces a potential $158 million deficit for the 2024-25 fiscal year and estimates that "significant assets will be needed to implement SB 43 and the state has not yet made additional resources available". County officials acknowledged that the combined requirements of SB 43 and the CARE Act would "mandate a dramatic reallocation of funds into the behavioral health department and force cuts to other departments and programs".

Systemic Challenges Across Counties: The experiences across these major county systems highlight common themes that may explain San Diego's lower-than-expected impact:

1. Resource Limitations: All counties implementing SB 43 have struggled with inadequate treatment beds and facilities. San Francisco has about 100 locked subacute treatment beds and rents another 48 from facilities as far away as Southern California, while officials estimate that 100 new beds would cost about $20 million annually to maintain.
2. System Bottlenecks: A recent study published by the California Health Care Foundation found that counties throughout the state pointed to problems with patient "throughput"—flow across the system of care—being obstructed by a lack of capacity at one or more different levels.
3. Emergency Department Strain: Many people placed on 5150 holds languish for days in hospital emergency departments while they await referrals to community-based services or placement in acute psychiatric units, a problem that exists regardless of SB 43's implementation.

Looking Forward

The experiences across major California county medical systems suggest that San Diego's lower-than-expected impact from SB 43 reflects broader systemic challenges rather than unique local factors. As San Diego County continues to monitor SB 43's implementation, the early results suggest that expanding legal criteria for involuntary treatment may not automatically translate to increased use of those powers without corresponding infrastructure investments.

County Behavioral Health Services Director Luke Bergmann emphasized the collaborative preparation effort: "I can't say enough about how all the stakeholders have come together to ensure we are properly, and compassionately applying this new law to help some of our most vulnerable residents."

The county plans to continue monitoring trends closely while working to address identified gaps in the treatment system and ensure that expanded legal authority translates into improved outcomes for people experiencing severe mental health and substance use crises. The comparative experiences suggest that successful implementation requires not just legal authority, but substantial investment in treatment infrastructure, staffing, and coordination across multiple systems of care.

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Sources

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9. Lawson-Remer, Terra. "Opinion: San Diego County's delay of conservatorship bill to address mental health is 'abhorrent'." The San Diego Union-Tribune, December 19, 2023. https://www.sandiegouniontribune.com/opinion/commentary/story/2023-12-19/opinion-san-diego-county-conservatorship-mental-health-homelessness-sb43
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