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AN ORDINANCE providing for the submission to the qualified electors of King County at a special election to be held in King County on April 25, 2023, of a proposition authorizing a property tax levy in excess of the levy limitation contained in chapter 84.55 RCW, for a consecutive nine-year period, at a first year rate of not more than $0.145 per one thousand dollars of assessed valuation for collection beginning in 2024, with the 2024 levy amount being the base for calculating increases in years two through nine (2025 - 2032) by the limit factor in chapter 84.55 RCW, as amended, for regional behavioral health services and capital facilities to establish and operate a regional network of behavioral health crisis care centers; to preserve, expand and maintain residential treatment facilities; to provide behavioral health workforce supports; to provide mobile crisis care and post-discharge stabilization; to pay, finance or refinance costs of those projects; and for administration, coordination, implementation and evaluation of levy activities.
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STATEMENT OF FACTS:
1. King County's behavioral health crisis service system relies heavily on phone support and outreach services, with very few options of places for persons to go for immediate, life-saving care when in crisis.
2. As of September 2022, the Crisis Solutions Center, operated by Downtown Emergency Service Center and requiring mobile team, first responder or hospital referral for entry, is the only voluntary behavioral health crisis facility for the entirety of King County, and no walk-in urgent care behavioral health facility exists in King County.
3. A coalition of community leaders and behavioral health providers issued recommendations to Seattle and King County in an October 13, 2021, letter that included recommendations to "expand places for people in crisis to receive immediate support" and "expand crisis response and post-crisis follow up services."
4. Call volume to King County's regional behavioral health crisis line increased by 25 percent between 2019 and 2021, from 82,523 calls in 2019 to 102,754 calls in 2021.
5. The number of persons per year who received community-based behavioral health crisis response services in King County increased 146 percent between 2012 and 2021, from 1,764 persons served in 2012 to 4,336 persons served in 2021.
6. Referrals for mobile crisis outreach in King County grew 15 percent between 2019 and 2021, from 4,030 referrals in 2019 to 4,648 referrals in 2021.
7. King County's designated crisis responders conducted 14 percent more investigations for involuntary behavioral health treatment in 2021, when they investigated 9,189 cases, than in 2017 when they investigated 8,066 cases. There was a 10 percent increase in detentions or revocations for involuntary hospitalization during that same period, from 4,387 in 2017 to 4,806 in 2021.
8. The wait time for a King County resident in behavioral health crisis in a community setting to be evaluated for involuntary behavioral health treatment tripled between January 2019 and June 2022, from 4 days to 12 days.
9. The U.S. Department of Health and Human Services reported that in August 2022, the first full month that the new national 988 Suicide and Crisis Lifeline was operational, the overall volume of calls, texts and chats to the Lifeline increased by 152,000 contacts, or 45 percent, compared to the number of contacts to the National Suicide Prevention Lifeline in August 2021.
10. The federal Substance Abuse and Mental Health Services Administration's ("SAMHSA's") National Guidelines for Behavioral Health Crisis Care, and its vision for the implementation of the new national 988 Suicide and Crisis Lifeline, call for the development of safe places for persons in crisis to go for help as part of a robust behavioral health crisis system.
11. In 2021, the Washington state Legislature passed Engrossed Second Substitute House Bill 1477, which became Chapter 302, Laws of Washington 2021, to support implementation of 988 in Washington, to further SAMHSA's overall vision and build on the crisis phone line change by expanding and transforming crisis services.
12. RCW 71.24.025 defines crisis stabilization services to mean services such as 23-hour crisis stabilization units based on the living room model, crisis stabilization centers, short-term respite facilities, peer-operated respite services, and behavioral health urgent care walk-in centers, including within the overall crisis system components that operate like hospital emergency departments and accept all walk-ins, and ambulance, fire, and police drop-offs. Chapter 302, Laws of Washington 2021 further expressed the state legislature's intent to expand the behavioral health crisis delivery system to include these components.
13. Multiple behavioral health system needs assessments have identified the addition of crisis facilities as top priorities to improve community-based crisis services in King County. Such assessments include the 2016 recommendations of the Community Alternatives to Boarding Task Force called for by Motion 14225, a Washington state Office of Financial Management behavioral health capital funding prioritization and feasibility study in 2018, and a Washington state Health Care Authority crisis triage and stabilization capacity and gaps report in 2019.
14. King County is losing mental health residential treatment capacity that is essential for persons who need more intensive supports to live safely in the community due to rising operating costs and aging facilities that need repair or replacement. As of August 2022, King County had a total of 244 mental health residential beds for the entire county, down 111 beds, or nearly one third, from the capacity in 2018 of 355 beds.
15. As of July 2022, King County residents who need mental health residential services must wait an average of 44 days before they are able to be placed in a residential facility.
16. Data from the U.S. Centers for Disease Control and Prevention, the U.S. Census Bureau and the Kaiser Family Foundation show that about three in ten adults in the United States reported symptoms of anxiety or depressive disorder in June 2022, up from one in ten adults who reported these symptoms in 2019.
17. The National Council for Mental Wellbeing's 2022 access to care survey found that 43 percent of U.S. adults who say they need mental health or substance use care did not receive that care, and they face numerous barriers to accessing and receiving needed treatment.
18. According to the Washington state Department of Social and Health Services, the number of Medicaid enrollees in King County with an identified mental health need increased by approximately 34 percent for adults and nine percent for youth between 2019 and 2021.
19. The Washington state Department of Social and Health Services reports that in 2021, among those enrolled in Medicaid in King County, nearly half of adults and over a third of youth with an identified mental health need did not receive treatment.
20. The Washington state Department of Social Health Services reports that in 2021, among those enrolled in Medicaid in King County, approximately 62 percent of adults and 80 percent of youth with an identified substance use disorder need did not receive treatment.
21. SAMHSA's National Guidelines for Behavioral Health Crisis Care recommend including peers with lived experience of mental health conditions or substance use disorders on crisis response teams. Those guidelines also feature the living room model as an example of crisis service delivery innovation featuring peers.
22. The 2021 King County nonprofit wage and benefits survey showed that many nonprofit employees delivering critical services earn wages at levels that make it difficult to sustain a career doing community-based work in this region.
23. A 2021 King County survey of member organizations of the King County Integrated Care Network found that job vacancies at these community behavioral health agencies were at least double what they were in 2019. Providers cited professionals' ability to earn more in medical systems or private practice, and the high cost of living in the King County region, as the top reasons their workers were leaving community behavioral healthcare.
24. The behavioral health workforce advisory committee to the state of Washington's Workforce Training and Education Coordinating Board found in 2021 that Washington continues to face a shortage of behavioral health professionals, while demand for services, and qualified workers to deliver them, continues to grow. The advisory committee also found that workers need increased financial support and incentives to remain in community behavioral health care.
BE IT ORDAINED BY THE COUNCIL OF KING COUNTY:
SECTION 1. Definitions. The definitions in this section apply throughout this ordinance unless the context clearly requires otherwise.
A. "Crisis care center" means a single facility or a group of facilities that provide same-day access to multiple types of behavioral health crisis stabilization services, which may include, but are not limited to, those described in RCW 71.24.025(20), as amended. A crisis care center shall endeavor to accept at least for initial screening and triage any person who seeks behavioral health crisis care. Among the types of behavioral health crisis stabilization services that a crisis care center shall provide are a behavioral health urgent care clinic that offers walk-in and drop-off client screening and triage twenty-four hours per day, seven days per week; access to onsite assessment by a designated crisis responder; a twenty-three-hour observation unit or similar facility and service that allows for short-term, onsite stabilization of a person experiencing a behavioral health crisis; and a crisis stabilization unit that provides short-term, onsite behavioral health treatment for up to fourteen days or a similar short-term behavioral health treatment facility and service. A crisis care center shall be staffed by a multidisciplinary team that includes peer counselors. A crisis care center may incorporate pre-existing facilities that provide crisis stabilization services so long as their services and operations are compatible with this definition. Where a crisis care center is composed of more than one facility, those facilities shall either be geographically adjacent or shall have transportation provided between them to allow persons using or seeking service to conveniently move between facilities.
B. "Designated crisis responder" has the same meaning as in RCW 71.05.020, as amended.
C. "King County crisis response zone" means each of four geographic subregions of King County:
1. North King County crisis response zone, which is the portion of King County within the boundaries of the cities of Bothell, Duvall, Kenmore, Kirkland, Lake Forest Park, Shoreline, Skykomish and Woodinville, plus the unincorporated areas within King County council district three as it is drawn on the effective date of this ordinance that are north or northeast of the city of Redmond;
2. Central King County crisis response zone, which is the portion of King County within the boundaries of the city of Seattle, plus all unincorporated areas within King County council districts two and eight as they are drawn on the effective date of this ordinance;
3. South King County crisis response zone, which is the portion of King County within the boundaries of the cities of Algona, Auburn, Black Diamond, Burien, Covington, Des Moines, Enumclaw, Federal Way, Kent, Maple Valley, Milton, Normandy Park, Pacific, Renton, SeaTac and Tukwila, plus all unincorporated areas within King County council districts five, seven and nine as they are drawn on the effective date of this ordinance; and
4. East King County crisis response zone, which is the portion of King County within the boundaries of the cities of Beaux Arts, Bellevue, Carnation, Clyde Hill, Hunts Point, Issaquah, Medina, Mercer Island, Newcastle, North Bend, Redmond, Sammamish, Snoqualmie and Yarrow Point, plus the unincorporated areas within King County council district three as it is drawn on the effective date of this ordinance that are east or southeast of the city of Redmond, plus all unincorporated areas within King County council district six as it is drawn on the effective date of this ordinance.
D. "Levy" means the levy of regular property taxes for the specific purposes and term provided in this ordinance and authorized by the electorate in accordance with state law.
E. "Levy proceeds" means the principal amount of moneys raised by the levy and any interest earnings on the moneys and the proceeds of any interim or other financing following authorization of the levy.
F. "Regional behavioral health services and capital facilities" means programs, services, activities, operations, staffing and capital facilities that: promote mental health and wellbeing and that treat substance use disorders and mental health conditions; promote integrated physical and behavioral health; promote and provide therapeutic responses to behavioral health crises; promote equitable and inclusive access to mental health and substance use disorder services and capital facilities for those racial, ethnic, experiential and geographic communities that experience disparities in mental health and substance use disorder conditions and outcomes; build the capacity of mental health and substance use disorder service providers to improve the effectiveness, efficiency, and equity, of their services and operations; provide transportation to care for persons receiving, seeking, or in need, of mental health or substance use disorder services; promote housing stability for persons receiving or leaving care from a facility providing mental health or substance use disorder services; promote service and response coordination, data sharing, and data integration amongst first responders, mental health and substance use disorder providers, and King County staff; promote community participation in levy activities, including payment of stipends to persons with relevant lived experience who participate in levy activities whose employment does not already compensate them for such participation; administer, coordinate and evaluate levy activities; apply for federal, state and philanthropic moneys and assistance to supplement levy proceeds; and promote stability and sustainability of the behavioral health workforce.
G. "Residential treatment" means a licensed, community-based facility that provides twenty-four-hour on-site care for persons with mental health conditions, substance use disorders, or both, in a residential setting.
H. "Strategy" means a program, service, activity, initiative or capital investment intended to achieve the purposes described in section 4 of this ordinance.
I. "Technical assistance and capacity building" means assisting organizations in applying for grants funded by the levy and in implementing and improving delivery of a strategy or strategies for which levy moneys are eligible, and includes assisting community-based organizations in delivery of strategies to persons and communities that are disproportionately impacted by behavioral health conditions.
SECTION 2. Levy submittal. To provide necessary moneys to fund, finance or refinance the purposes identified in section 4 of this ordinance, the King County council shall submit to the qualified electors of the county a proposition authorizing a regular property tax levy in excess of the levy limitation contained in chapter 84.55 RCW for nine consecutive years, with collection commencing in 2024, at a rate not to exceed $0.145 per one thousand dollars of assessed value in the first year of the levy period. The dollar amount of the levy in the first year shall be the base upon which the maximum allowable levy amounts in years two through nine (2025-2032) shall be calculated using the limit factor in chapter 84.55 RCW, as amended.
SECTION 3. Deposit of levy proceeds. The levy proceeds shall be deposited into the crisis care centers fund, or its successor.
SECTION 4. Levy purposes.
A. The paramount purpose of the levy shall be to establish and operate a regional network of five crisis care centers in King County, with each of the four King County crisis response zones containing at least one crisis care center and at least one of the five crisis care centers specializing in serving persons younger than nineteen years old.
B. The levy's supporting purpose one shall be to restore the number of mental health residential treatment beds in King County to at least three hundred fifty-five beds and to expand the availability and sustainability of residential treatment in King County.
C. The levy's supporting purpose two shall be to increase the sustainability and representativeness of the behavioral health workforce in King County by increasing recruitment and retention, and by improving financial sustainability for the behavioral health workforce through increased wages, apprenticeship programming and, where possible, reduction of costs such as costs of insurance, child care, caregiving and fees or tuition associated with behavioral health training and certification. This purpose shall promote workforce recruitment and retention for the region's behavioral health workforce while prioritizing increased wages and reduction of costs for the behavioral health workforce who are providing regional behavioral health services and capital facilities as a part of the levy's paramount purpose.
D. The levy implementation plan required by section 7 of this ordinance may specify additional supporting purposes so long as those additional supporting purposes are not inconsistent with and are subordinate to the paramount purpose and supporting purposes one and two described in subsections A. through C. of this section.
SECTION 5. Eligible expenditures.
A. If approved by the qualified electors of the county, such sums from the first year's levy proceeds as are necessary may be used to provide for the costs and charges incurred by the county that are attributable to the election, and an amount from the first year's levy proceeds not to exceed one million dollars may be used for initial levy implementation planning activities.
B. After the amounts authorized in subsection A. of this section, the remaining levy proceeds shall not be expended until King County enacts an ordinance adopting the implementation plan required by section 7 of this ordinance. The council's process to consider and adopt the levy implementation plan and any amendments shall include mandatory referral to the regional policy committee or its successor. After King County enacts an ordinance adopting the levy implementation plan, levy proceeds shall be expended in accordance with the implementation plan, as amended, and with this ordinance.
C. Levy proceeds described in subsection B. of this section shall only be used to fund, finance or refinance costs to:
1. Plan, site, construct, acquire, restore, maintain, operate, implement, staff, coordinate, administer and evaluate regional behavioral health services and capital facilities that achieve and maintain the paramount purpose, supporting purpose one, and supporting purpose two of the levy that are described in section 4. and as they may be further described in the implementation plan;
2. Plan, site, construct, acquire, restore, maintain, operate, implement, staff, coordinate, administer and evaluate regional behavioral health services and capital facilities that achieve additional levy purposes that are included in the implementation plan, so long as those purposes are subordinate to and not inconsistent with the paramount purpose and supporting purposes one and two; and
3. Provide for regional behavioral health services and capital facilities provided by metropolitan park districts, fire districts or local public hospital districts in King County in an amount up to the lost revenues to the individual district resulting from prorationing, as mandated by RCW 84.52.010, to the extent the levy was a demonstrable cause of the prorationing and only if the county council has authorized the expenditure by ordinance.
D. Unless made otherwise eligible in subsection C. of this section, levy proceeds shall not be used to provide, supplant, replace or expand funding for non-behavioral health purposes including, but not limited to, jails, prisons, courts of law, criminal prosecution, criminal defense or law enforcement, except for costs that provide or coordinate regional behavioral health services and capital facilities within or between crisis care centers and other health care settings or that remove or reduce a barrier to receiving behavioral health services such as quashing a warrant. Nothing in this subsection shall be interpreted or construed to limit, discourage, or impede law enforcement agencies' or other first responders' coordination with, use of and access to crisis care centers for persons they encounter in the conduct of their duties.
SECTION 6. Call for special election. In accordance with RCW 29A.04.321, the King County council hereby calls for a special election to be held on April 25, 2023, to consider a proposition authorizing a regular property tax levy for the purposes described in this ordinance. The King County director of elections shall cause notice to be given of this ordinance in accordance with the state constitution and general law and to submit to the qualified electors of the county, at the said special county election, the proposition hereinafter set forth. The clerk of the council shall certify that proposition to the director of elections in substantially the following form:
PROPOSITION___: The King County Council passed Ordinance ____ concerning funding for mental health and substance use disorder services. If approved, this proposition would fund behavioral health services and capital facilities, including a countywide crisis care centers network, increased residential treatment; mobile crisis care; post-discharge stabilization; and workforce supports. It would authorize an additional nine-year property tax levy for collection beginning in 2024 at $0.145 per $1,000 of assessed valuation, with the 2024 levy amount being the base for calculating annual increases in 2025-2032 under chapter 84.55 RCW, and exempt eligible seniors, veterans, and disabled persons under RCW 84.36.381. Should this proposition be:
Approved? _____
Rejected? _____
SECTION 7. Implementation plan.
A. If voters approve the levy, the executive shall transmit by December 31, 2023, a proposed levy implementation plan for council review and adoption by ordinance. The proposed implementation plan shall direct levy expenditures from 2024 through 2032.
B. The executive shall electronically file the implementation plan required in subsection A. of this section with the clerk of the council, who shall retain the original and provide an electronic copy to all councilmembers, the council chief of staff, the policy staff director and the lead staff for the law, justice, health and human services committee and the regional policy committee, or their successors. The implementation plan shall be accompanied by proposed ordinances that adopt the implementation plan and that establish or empower the advisory body, the description of which is set forth in subsection C.9. of this section.
C. The implementation plan required in subsection A. shall include:
1. A list and descriptions of the purposes of the levy, which must at least include and may not materially impede accomplishment of the paramount purpose and supporting purposes one and two described in section 4 of this ordinance;
2. A list and descriptions of strategies and allowable activities to achieve the purposes described in subsection C.1. of this section, which strategies shall at least include:
a. planning, capital, operations and services investments for crisis care centers, which may include construction of new or acquisition, renovation, updating or expanding existing buildings in whole or in part;
b. capital and maintenance investments for mental health residential treatment capacity;
c. investments to increase attraction to, retention in, and sustainability of the behavioral health workforce;
d. establishment and maintenance of levy and capital reserves to promote continuity of levy-funded activities and prioritization of the paramount purpose and then supporting purposes one and two in the event of fluctuations in levy revenue or strategy costs;
e. activities that promote post-crisis stabilization, including housing stability, for persons receiving or discharging from levy-funded services;
f. a plan for the initial period of the levy prior to initiation of operations of the first crisis care center for the provision of mobile and site-based behavioral health activities that promote access to behavioral health services for persons experiencing or at risk of a behavioral health crisis;
g. technical assistance and capacity building for organizations applying for or receiving levy funding, including a strategy or strategies to promote inclusive care at levy-funded facilities for racial, ethnic and other demographic groups that experience disproportionate rates of behavioral health conditions in King County;
h. capital facility siting support, communication and city partnership activities;
i. levy administration activities and activities that monitor and promote coordination, more effective crisis response, and quality of care within and amongst crisis care centers, other behavioral health crisis response services in King County, and first responders; and
j. performance measurement and evaluation activities;
3. A financial plan to direct the use of the proceeds for regional behavioral health services and capital facilities that achieve the purposes and strategies described in subsection C.1. and 2. of this section, which must at a minimum include:
a. the forecast of annual revenue for each year of the levy;
b. an annual expenditure plan for each year of the levy that allocates forecasted levy proceeds among the levy's strategies;
c. a description of the sequence and timing of planned expenditures and activities to establish and operate the regional network of five crisis care centers required to satisfy the levy's paramount purpose; and
d. a description of how a portion of first-year levy proceeds will be allocated to make rapid initial progress towards fulfilling supporting purposes one and two;
4. A description of how the executive will seek and incorporate when available federal, state, philanthropic and other moneys that are not proceeds of the levy to accelerate, enhance, compliment or sustain accomplishment the levy's paramount purpose and supporting purposes one and two;
5. A description of the executive's assumptions about the role of Medicaid funding in the financial plan and the executive's planned approach to billing eligible crisis care services to Medicaid or other sources of potential payment such as private insurance;
6. A description of the process by which King County and partner cities shall collaborate to support siting of new capital facilities that use proceeds from the levy for such facilities' construction or acquisition;
7. A summary of the process and key findings of the community and stakeholder engagement process that informs the proposed implementation plan;
8. A process to make substantial adjustments to the financial plan required in subsection C.3. of this section, which process shall require notice to the council and provide for the council the ability to stop any substantial adjustment that the council does not support;
9. A description of the composition, duties of, and process to establish the advisory body for the levy. The advisory body may be a preexisting King County board or commission that has relevant expertise or a new advisory body. The composition of the advisory body shall be demographically representative of the population of King County and shall include at least one resident of each King County crisis response zone, persons who have previously received crisis stabilization services, and persons with professional training and experience in the provision of behavioral health crisis care. The duties of the advisory body shall include advising the executive and council on matters pertaining to implementation of the levy, annually visiting each existing crisis care center and reporting annually to the council and community, through online annual reports beginning in 2025, on the levy's progress over the previous year towards accomplishing the levy purposes described in section 4 of this ordinance and on the levy's actual financial expenditures in the previous year relative to the financial plan required in subsection C.3. of this section that shall include, but not be limited to, the following:
a. total expenditure of levy proceeds by crisis response zone, strategy, and levy purpose by ZIP Code in King County; and
b. the number of individuals receiving levy-funded services by crisis response zone, strategy, and levy purpose by ZIP Code in King County of where the individuals reside at the time of service;
10. A description of how the executive shall provide each online annual report described in subsection C.9. of this section to the clerk of the council, to all councilmembers and all members and alternate members of the regional policy committee, or its successor, including confirmation that the executive shall electronically file a proposed motion that shall acknowledge receipt of the report; and
11. A description of how the purpose of the crisis response zones described in this levy will promote geographic distribution of crisis care centers so that they are accessible for walk-in and drop-off crisis care throughout King County, but that the crisis care zones shall not be used to limit the ability of any person in King County to use any particular crisis care center.
SECTION 8. Updating the definition of crisis care center. If new research, changing best practices, updated federal or state regulations or other evidence-based factors cause this ordinance's definition of "crisis care center" to become infeasible, impracticable or inconsistent with the levy's paramount purpose, King County may, upon recommendation of the advisory body described in section 7.C.9. of this ordinance and with mandatory referral to the regional policy committee, update the definition of "crisis care center" through adoption of an ordinance to a definition substantially similar to what is recommended by the advisory body.
SECTION 9. Exemption. The additional regular property taxes authorized by this ordinance shall be included in any real property tax exemption authorized by RCW 84.36.381.
SECTION 10. Ratification and confirmation. Certification of the proposition by the clerk of the county council to the director of elections in accordance with law before the special election on April 25, 2023, and any other act consistent with the authority and before the effective date of this ordinance are hereby ratified and confirmed.
SECTION 11. Severability. If any provision of this ordinance or its application
to any person or circumstance is held invalid, the remainder of the ordinance or the application of the provision to other persons or circumstances is not affected.