Lindsey Pope didn’t think she needed help.
For six years, the now 29-year-old lived between homelessness and jail, always at the mercy of her crystal meth addiction. She abandoned her nursing career goals, squandered her money and possessions, and lost custody of her baby son. As long as she had drugs, she didn’t care.
Finally, after her fifth probation violation, a Los Angeles judge gave Pope an ultimatum: Spend four-and-a-half years in state prison, or enter a treatment program for substance abuse. She chose the latter, but remained unconvinced that the program would help her.
“I never knew anything about rehab or how to go about getting into rehab,” said Pope, who is now more than half way through a residential treatment program for women at Prototypes in Pomona.
“Before, I never would have saw myself here,” she said.
Pope entered her program in November, just four months after Los Angeles County launched a radical shake-up in how it provides substance abuse treatment for low-income adults. The change is directed at people who qualify for Medi-Cal, California’s health insurance program for the poor, known nationally as Medicaid.
The new treatment approach is part of a pilot program being implemented gradually across the state that aims to provide comprehensive, long-term addiction treatment to more people.
So far 10 counties have launched the new program, including Los Angeles, Riverside, San Francisco and San Luis Obispo. Another 30 counties are expected to follow suit this year. Some smaller counties have decided not to join the program because they don’t have the capacity to make it work, officials said.
In counties operating the program, low-income patients like Pope can get access to multiple stages of substance abuse treatment free, all covered by Medi-Cal. That includes residential treatment (usually up to three months), detoxification, medication-assisted treatment, outpatient services, individual and group therapy, doctor’s appointments, and case management. Patients get assigned to a specific level of treatment based on their needs. Once they complete that, they’re encouraged to continue with follow-up care indefinitely to support their recovery.
That’s not how things worked in the past.
Treating Addition Like Chronic Disease
Under the old system, Medi-Cal coverage for substance abuse treatment was much more limited. In addition to a smaller range of outpatient services, enrollees could not get residential treatment unless they were pregnant or had just given birth. Some counties would pay for residential treatment themselves using federal block grants or general-fund dollars. But this was rarely enough to meet demand, and people needing treatment would often languish for weeks on waiting lists or never get into a residential program, health officials and providers said.
The new system, called the Drug Medi-Cal Organized Delivery System, tackles substance-use disorder much like any other chronic disease, such as diabetes or heart disease, said Marlies Perez with the state Department of Heath Care Services, which oversees Medi-Cal. Patients receive ongoing checkups and support to help prevent relapse, and to catch and treat it quickly if it happens.
Counties participating in the pilot take responsibility for managing the drug-treatment system for Medi-Cal beneficiaries. They must ensure there are enough providers to meet demand, and that patients are assessed and treated according to a common set of scientific standards defined by the American Society of Addiction Medicine. Counties can also negotiate higher Medi-Cal payments for providers as a way to encourage more of them to accept the plan’s patients.
“This system really replaces a non-system,” explained Catherine Teare, who works at the California Health Care Foundation to support counties implementing the new program. “It’s really the first in the nation to have a standardized set of evidence-based services for substance use disorder treatment and to refer people who need the services to them in a fairly ordered manner.”
More Californians Getting Treatment
The federal Centers for Medicare and Medicaid Services authorized the pilot program in 2015, underwriting most of the cost of the expansion. The federal government pays for about 69 percent of the cost of Medi-Cal, including the drug treatment program. The state’s general fund covers about 18 percent of the cost, and counties pick up the 13 percent remainder.
California is the first state in the country to enact this sweeping change, although a few other states have since been approved to start their own substance use treatment initiatives. The pilot is initially approved until 2020, but state officials hope it will be extended.
In addition to improving the lives of patients and their families, the goal of the program is also to save money, Perez said. By providing accessible, quality treatment over the long-term, it’s hoped that fewer people will need expensive emergency care, and they’ll be less likely to relapse and require intervention from the criminal justice system and child and family services, she said.
Darren Urada, a research psychologist at UCLA, is in charge of evaluating the program. The evaluation will look at whether the pilot is reducing emergency room use and hospitalization, whether the quality of care improves, and if more patients access care. Data is only just starting to come in and preliminary results won’t be available until at least the summer, he said. However, signs so far point to more patients accessing treatment.
“We do know right now in the counties that have started, in terms of medical billing, there was a definite jump,” Urada said. “That’s happening, but we need to dig into that further.”
Reaching everyone in need will take time. According to federal data, fewer than 1 in 10 Californians who need treatment for drug abuse actually get it. That means nearly 800,000 people across the state went without treatment in the 2013-14 fiscal year, the most recent data available.
Many of those who don’t get treatment are enrolled or eligible for Medi-Cal. The Department of Health Care Services estimates at least 12 percent of adult Medi-Cal beneficiaries have a substance-abuse disorder.
John Connolly, acting deputy division director of Substance Abuse Prevention and Control for Los Angeles County, said the new system has made it much easier for people to get help. Patients used to wait weeks for treatment but can now get it right away, he said. Waitlists are not allowed under pilot program rules.
“I think it’s a generational deal,” he said. “It’s as big a change as this field has seen in decades. It’s a total reorientation of the entire system.”
At Prototypes, run by a larger community healthcare provider called HealthRIGHT 360, behavioral health managing director Danielle Buckland said the new funding has allowed her to hire 10 new staff members, including therapists and case managers. She’s also been able to provide more training for staff, and implement better quality therapy programs for clients, she said. She can even consider scaling up the program to treat more patients, an option that was never available in the past, she said.
“Before, no matter what I did I was always going to get the same amount of money. Here it’s limitless, so in that sense for our organization that’s a huge opportunity for growth,” she said. “Before I was always limited to the number of clients I could really serve with that money. Now, as long as there’s a client in need we’re not going to have to say, ‘No, I’m so sorry, our block grant’s out.’”
Tarzana Treatment Centers, a community-based provider of behavioral health services in L.A. County, is already expanding. The non-profit plans to add four new residential and outpatient sites to its existing 15, said Albert Senella, president and CEO. After years of having to leave beds empty in residential facilities and turn people away because of lack of funds, the organization can now fill almost all of its beds every day, he said.
The pilot program “is the best thing that’s happened to the field,” he said. “There’s never been a commitment to substance use disorder treatment like this ever before.”
Finding Affordable Housing
But there are concerns about the new system. One widely criticized provision is the 90-day limit on residential treatment, which providers said is too short for some patients. At Prototypes, for example, patients used to stay as long as 18 months, Buckland said.
Vitka Eisen, CEO of HealthRIGHT 360, said longer stays give providers in her organization a chance to find stable housing for patients, many of whom are homeless. It’s hard to do that in three months, she said, especially given the affordable housing shortage in many parts of California.
“It’s pretty impossible to maintain what you’ve gained and benefited from treatment and then not know where you’re going to sleep at night,” she said. “Without a stable source of income and safe housing and a social support system, then people are likely to return to drug use.”
Another concern is Republican-led efforts to repeal the federal Affordable Care Act, which, if successful, would cut a large group of newly eligible Medi-Cal beneficiaries out of the program.
Some providers also lamented the avalanche of new procedures and paperwork requirements that come with participation in the new system.
Connolly, the Los Angeles County deputy director, agreed the transition to the new system will take some adjustment.
“This is a massive change and it’s a very big deal and with anything that’s that disruptive, no matter how good the goals and the intentions are, it takes time for us to really see the positive effects,” he said.
For Pope, treatment at Prototypes has restored her hope of reuniting with her son, who is in the care of her mother. Pope also wants to find long-term housing and return to her nursing studies.
She’s scheduled to remain at the residential facility until May, and then transition to a sober-living home followed by outpatient care. She takes daily group-therapy classes that she said have taught her how to work through her past experiences and process her emotions without the need for drugs.
“They teach you how to be sober and stay sober,” Pope said. “I feel a lot better… I didn’t think it was going to work. Now I know it’s going to work.”