In California, New Drug Treatment Money Also Means New Rules

Lindsay grew up in and out of foster homes in Oakland. At 15, she ran away and soon got into methamphetamine. When she was later living in Peoples’ Park in Berkeley, meth helped her stay awake and avoid feeling hungry. And as a woman, it was easy to get.

"Because men are like, 'I want to have fun, let's hang out. Let's get you high and see what happens,' " Lindsay says, referring to meth’s effect of reducing sexual inhibitions. "That was when it started to become more of a problem – when I started relying on my womanly self to get high."

Lindsay, who asked that we not use her last name because of her drug use, is now 31. Last year, when she was homeless and pregnant, she agreed to go into treatment, and spent seven months at a residential treatment center for women and their babies in San Francisco, called the Epiphany Center. She is now working and living on her own. Other women who have completed the program often stayed for up to a year.

But these long, unfettered stays won't be possible anymore, as new policies on how long patients can remain in residential treatment programs take effect on July 1 in San Francisco. An influx of federal money is allowing counties throughout the state to get more people into treatment. But with federal money comes federal limits on how to spend it. People will only be allowed to stay in residential treatment for up to 90 days. And if they drop out of treatment, even after a few days, they only have one chance that year to try again.

Many drug treatment providers are worried these restrictions could make it harder for some users, like Lindsay, to get the help they need.

"These are folks who have really been victimized and they need time to heal," says Suzi Desmond, chief operating officer and director of adult services at Epiphany. "To unearth the trauma, and go through the pain of the trauma, and really come out the other side, it takes considerable time for the healing."

Providers are especially concerned about the cap of two residential treatment stays per year. People leave treatment prematurely for all kinds of reasons, including family emergencies or because they just got overwhelmed. Plus, drugs like meth alter a person’s brain, making it harder to control impulses and make decisions — like whether to stay in treatment.

"This is not an easy program,” Desmond says of Epiphany. "So you have folks who say 'I can't deal with this. I'm out of here.' So it’s potentially very problematic."

Changing Drug Treatment Rules

The changes stem from a new pilot project — Drug Medi-Cal – which is overhauling how drug treatment gets delivered and paid for in California. Under previous rules, drug treatment options were scarce, and residential treatment facilities, in particular, were limited in number and size and were primarily available to pregnant and postpartum women only.

The new project aims to expand residential treatment to all low-income adults and improve treatment overall. In the first year, there was a roughly 20% increase in people entering residential treatment, according to data from UCLA.

California is the first state in the country to try this new model — with more than 20 other states planning to follow suit — and San Francisco is one of the first counties in the state to implement it. Forty other counties also plan to opt into the program.

The increases in treatment are possible because of funding changes. In the past, treatment dollars came from the state and counties - San Francisco chipped in quite a bit from its own coffers. Now, the federal government is covering 90% of the bill.

And in order not to drain the budget, officials set new restrictions on length of stay and number of stays in residential treatment.

But experts question if these rules are fair, or even legal, specifically limiting treatment to two episodes per year.

"I think I would sue if I were in that situation," says Keith Humphreys, a Stanford psychiatry professor, who was in the room when Congress wrote the law requiring that mental health conditions be treated on par with physical conditions.

"So unless they're saying you can't have more than two heart attacks a year, they should not be allowed to say you can't have more than two drug problems in a year," he says.

The new rule could adversely impact meth users, in particular, Humphreys says, at a time when San Francisco is facing an epidemic rise in meth use, hospitalizations and overdoses. There are no medication treatments for meth to help with cravings, like there are for opioids – just behavioral therapies, which are slower, longer and harder to administer.

"If it's harder to treat, then being cut off — you can only have one shot every six months — is going to fall more heavily on that population," Humphreys says.

Historically, how long a person stays in treatment has been determined by how much insurance companies will pay, or how much treatment a judge thinks a person deserves as an alternative to jail time.

The goal of the Drug Medi-Cal program is to root these decisions in science, and according to the science, there is no magic number of treatment days that works or doesn’t work. Humphreys says 90 days could be fine, as long as people get plenty of support afterward.

"It's not like a tumor you can remove or a broken bone you can set. It's a chronic condition," he says. "What happens after the acute phase of treatment matters enormously. So the more support you can give, the longer you can extend it, the better off they’re going to be."

San Francisco Stands Out

This is where San Francisco’s approach stands out. Now that it has the new federal money for treatment, the county is reinvesting the money it's saving into housing. So when patients' 90 days are up, rather than being discharged back out onto the streets, they can move into transitional housing and keep going with outpatient treatment for a year.

The result is that the overall amount of time people are in care has actually lengthened, says Vitka Eisen, CEO of HealthRIGHT 360, who has been testing the new rules at her treatment centers in San Francisco for the last couple years, ahead of the citywide roll out in July.

At first she was worried about the treatment limits, but Eisen is seasoned at adapting to ever-changing health care policies, and she’s come to appreciate the benefits of the new Drug Medi-Cal program. She says a lot more people who need residential drug treatment are now able to get it, they stay longer in outpatient treatment and the federal funding has brought more stability to the clinics.

"It's actually better than it was before," she says.

In the past, every time there was an economic downturn, Eisen and her colleagues were at the mercy of local officials looking for ways to cut the budget. Programs like hers that relied solely on local money, with no federal contribution, were always the first to go.

"So every year we would be throwing ourselves on the floor of the health commission, saying 'Don’t cut our programs!'" she remembers. "Sometimes we would be successful, but there was one year where we weren't and we literally closed our outpatient substance-use-disorder program."

Now that the federal government is paying for most of the treatment costs, local officials are much less likely to nix them. So Eisen has taken the new federal restrictions in stride. At HealthRIGHT 360, they converted 88 of their 300 residential beds into transitional beds and converted two of their residential treatment centers into transitional housing.

"This building used to be a convent," she explains, walking through the chapel and past the rows of small bedrooms at their new transitional house on Haight Street. Now it’s just for men.

Transitional Housing 'A Gift'

Last fall, some of Daniel Giles' friends pooled money to get him into a private rehabilitation center near his home in Humboldt County, to help him get off heroin. That county has not rolled out the new Drug Medi-Cal program yet, so there is no publicly funded residential treatment available. The private-pay programs Giles was considering were only 60 days long.

"I didn’t think I was going to get what I needed out of 60 days," he says. "Coming down here, my friend had told me that you can get funding through the state."

He got enrolled in the Drug Medi-Cal program and went through his 90 days of intensive residential treatment at San Francisco’s Walden House, then moved to the transitional house on Haight Street in February. He’s still in therapy and taking lots of classes on how to cope with stress and improve his self-esteem.

Giles has struggled with drugs and alcohol for 25 years. He’s covered with tattoos that say things like "Born Dead" and "Epic Fail."

"That goes to show how my mind worked in the past, and how I felt about myself," he says.

That's a lifetime of negative thinking he's trying to overhaul, he says. For as well as he's doing now, with seven months sober, he still feels far from ready to get a job or be on his own.

"A lot of people try to do it too quickly, and you got to remember the lifestyle I came from was very excitable, very escapism based," he says. “Learning to just sit and be with the person that I am today — it has been a huge change for me.”

Only a handful of counties are investing in housing to the degree San Francisco is. Many counties don't have the money — or the will — to do the same thing. And even San Francisco's transitional housing programs are vulnerable — they rely on the same local funding that was routinely cut in prior years.

Giles says having this extra year, post-treatment, to get back on track has been a blessing. Without it, he says he doesn't know where he'd be. Going back home to Humboldt, back to all his old friends and bad influences, is something he doesn't want to think about.

"Man, that's a scary thought," he says. "That’s why I try not to squander this gift."