Confusion and Tension Between Counties as California Tests New Drug Treatment Program

When Daniel Giles blinks, it looks like he might be wearing eye makeup. He has a tattoo across each of his eyelids that says "Born Dead."

“It’s kind of like an existential reminder not to live in the past and to remember that I’m not always promised a tomorrow,” he says of his ink. “They’re a symbol of where I’ve been and what I’ve been through.”

Giles was working in a redwood lumber mill in Humboldt County when his hand got crushed in an accident. He got hooked on the opiate pills the doctor prescribed for pain. Then he graduated to heroin. As he watched his friends overdose, he was afraid he was next.

But the drug treatment options there were slim. A friend told him about some great services in San Francisco.

“So I came down here. I raised a white flag of surrender, and I just came down here and checked myself in,” he says.

Giles has been in treatment since last November. San Francisco is one of the first counties in the state to roll out new updates to the Drug Medi-Cal program. Now the state gets more federal money to provide residential treatment for more people. But each county is responsible for running its own program. So while some bigger counties have gone all in, many rural counties, for financial or political reasons, have implemented the changes on a smaller scale; 18 opted out altogether.

“That creates a really perverse incentive,” says Stanford psychiatry professor Keith Humphreys, warning that some counties could exploit others’ willingness to act by doing nothing.

In Santa Clara County, where he lives, services are so generous that patients refer to it as Santa Claus County.

“So if you are a county that decides to invest a lot in addiction and mental health, does that lead other counties to say, ‘Why don't we just give people bus tickets, rather than putting up our own money?’ ” Humphreys says.

San Francisco was afraid of this. It considered a rule that said people who wanted to come here for treatment had to establish residency in the county first. That can take 60 days.

Treatment providers flipped.

“They could die! They could literally die between today and tomorrow,” says Vitka Eisen, CEO of HealthRIGHT 360, which has been testing the new Drug Medi-Cal program at its treatment centers in San Francisco for two years.

“A person who comes in for substance use disorder treatment today needs it today,” she says. “Because if they don’t, if we put any barrier up, they’re not going to get that treatment. What they might do is go around the corner and use drugs.”

In the end, San Francisco decided to admit people from other counties into residential treatment right away, as long as they agree to transfer their Medi-Cal benefits from their home county to San Francisco. But the state doesn’t pay until the transfer goes through, leaving San Francisco on the hook for those bills during the 60-day interim.

It’s unclear if other counties in a similar position will be that generous.

“There's a lot of both confusion and tension around this county-by-county thing, particularly services that not every county has, like methadone treatment for opioid addiction,” says Margaret Kisliuk, the behavioral health administrator at Partnership HealthPlan, the insurer that is working to implement the new Drug Medi-Cal program in rural counties in Northern California. “It’s really hard if some counties are in and some are out.”

Humboldt County has an aggressive plan to implement the new program, she says, but it hasn’t yet. So residential treatment wasn’t available to Daniel Giles there when he decided he was ready to get sober. But he says he didn’t really want to do it in Humboldt anyway.

“Because I had two years on the streets. I knew a lot of people, and I know myself,” Giles says. “So, when I got out I think that it would have been really hard for me to separate myself in a small town from the people I’d gotten to know.”

He was in treatment for seven months — three in intensive residential treatment and four in outpatient treatment while he lived in one of San Francisco’s county-funded transitional housing units. He says, for him, starting his life over was best to do someplace far from home.