In 1988, Angela Porter hit bottom. She was just 22 years old at the time, but her crack cocaine habit had consumed her life. She lost her friends, her family, her home, and her dignity. Homeless, alone, and broke, she resorted to knocking on people’s doors in Berkeley and begging for money.
As she slept in some bushes one night, a man tried to rape her. She fought him off and barely got away. “I was dirty, broken, and too ashamed to reach out to my family,” Porter recalled in a recent interview.
One morning, as she walked the streets of Berkeley, a desperate, cocaine-addicted wraith of her former self, everything seemed to be going in slow motion. She hadn’t slept in four days, and she was certain she was hearing things.
She picked a house at random and knocked on the door. Porter asked the woman who answered if she could use the phone. Inside, Porter pretended to make a call, as the woman stood nearby making breakfast. Porter then spotted a purse on the floor. She hung up the phone, grabbed the purse, and made a beeline for the front door. Once outside, she was too sickly to run, so she hobbled down the street. She made it about two blocks from the house before a neighbor who looked like he weighed about four hundred pounds chased after her on a moped. The large man jumped off, tackled her, and then lay on top of her until police arrived.
After spending three days in jail, Porter never wanted to go back. A couple of inmates beat her and stole her blankets. Jail smashed through the drug-fueled madness that had clouded her reasoning. ‘”What has happened to me? What have I become?”‘ she recalled asking herself. She remembered all the things she had done — things she had told herself she would never do — for drugs. ‘”This is not who I am. I need help.”‘
The court offered her the chance to go to rehab — or spend two years in Santa Rita Jail. She chose rehab.
Porter went to New Bridge Foundation, a long-term residential facility in Berkeley that caters to the most stubborn and hardcore drug and alcohol abusers who can’t afford private treatment. At New Bridge, residents live in a highly structured environment and adhere to strict rules. The program is designed to get at the core issues affecting drug abusers and change the way they think and behave. Through structure, discipline, and group therapy, Porter learned how to stay off drugs, be responsible, and function in society.
But getting sober wasn’t easy. New Bridge is a long and challenging program. Back then, the inpatient program lasted twelve to eighteen months, with another six months in supportive housing, which was still structured, although clients could leave for work and have social time.
Over the years, the number of long-term residential treatment programs like New Bridge has declined in the East Bay and throughout the state, fueled in part by a lack of funds and by newer treatment methods, which favor shorter stays and more outpatient programs in which clients take classes by day and return home at night. As a result, New Bridge and many other publicly funded long-term residential centers in California have been forced to shorten their programs to no more than six months.
And if the state gets its way, the lengths of stay might get even shorter — so much so that it wouldn’t be accurate to call such treatment long-term anymore.
Right now officials for MediCal — California’s version of the federal Medicaid health insurance for the poor — are ironing out the details with the federal government on what could be the most significant overhaul of the substance abuse field in California history. If approved, the planned changes would radically transform the substance abuse landscape, altering how providers do business and how poor people like the 22-year-old Porter get treatment. The state is promising to provide more people with more treatment options, including detox, methadone maintenance, and outpatient care. Most importantly, for the first time, it will offer short-term residential care to those with MediCal.
But the overhaul may also result in the death of the long-term residential care system as we know it by limiting stays to no more than ninety days. Porter said some of the reforms proposed by MediCal officials make sense. A lot of people who didn’t have access previously to residential care would now have that benefit, she noted. However, while the planned overhaul might look good on paper, “what happens to folks who need more services?” she asked.
For Porter, treatment is more than just getting people clean and sober. It is about learning how to live. “If I didn’t go to New Bridge,” she said, “I’d be dead.”
In 1965, Congress created Medicaid, a sweeping federal program that gives children, low-income parents, the disabled, and the elderly access to medical services that they otherwise can’t afford. California’s version of the new medical assistance program is called MediCal, and both the federal and state governments fund it.
But within the law establishing Medicaid, Congress banned funding for residential care facilities. The ban was intended to keep states from warehousing the mentally ill, but it also applied to substance abuse treatment centers.
The exclusion, however, has exceptions. MediCal will pay for substance and mental healthcare residential treatment programs for women in the perinatal period — just before, during, and after birth of a baby. The ban also only applies to residential facilities with more than sixteen beds. However, the high cost of operating a residential rehab makes it nearly impossible to financially survive on sixteen or fewer beds. In California, 90 percent of publicly funded rehabs have more than sixteen beds, meaning they mostly survive on non-MediCal funding.
Without MediCal funds, long-term residential programs developed largely on their own, outside the mainstream healthcare system, with little to no oversight. Many long-term rehabs use an abstinence-based approach, relying on the twelve steps of Alcoholics Anonymous and group therapy, and some are run by former addicts who don’t have degrees or formal training.
For decades, long-term rehabs such as New Bridge have survived on a patchwork of federal block grants and county dollars. Historically, the biggest funder of block grants has been the Substance Abuse and Mental Health Services Administration, a federal agency that doesn’t place any restrictions on lengths of stay. The federal government gives block grants to states, which then distribute the funds to individual counties, which, in turn, dole out the money to providers with which they contract. Long-term providers currently receive about $100 per patient, per day.
But even though the current system funds long-term facilities such as New Bridge, it has numerous shortcomings. Tom Renfree, the executive director of the County Behavioral Health Directors Association, which represents the state’s 58 counties, explained that substance abuse treatment in California has always been underfunded. And the MediCal residential care exclusion made matters worse by causing a shortage of services for the poor. The current system results in limited space and wait lists that are sometimes two to three months long. People looking for treatment also must often navigate a disjointed and unfamiliar terrain. Roughly, only one in ten people wanting treatment actually get the services they need, he said. And those who don’t get help end up clogging emergency rooms, shelters, and jails. In California, Renfree said, drug treatment is organized in two tiers: “a Cadillac system of care for rich people and an underfunded system of care for poor people.”
When the Affordable Care Act, also known as Obamacare, went into effect in 2014, most poor people in the state became eligible for MediCal. Today, 11.3 million Californians are enrolled in the program, according to state Department of Health Care Services spokesperson Carol Sloan. The Affordable Care Act acknowledged that substance abuse is a serious health problem and set aside a pot of money specifically for the treatment of it. But in order for the state to get a share of this pot, it needed to reform how it delivers substance abuse services. Obamacare offered the state the opportunity to beef up its substance abuse programs and lift the ban on residential treatment — but only up to a point.
State health care officials spent the last year drafting a proposal to reform the system based on input from drug treatment providers and county behavioral health employees. One of the most important components of the reform is the inclusion of short-term residential care. State officials, however, don’t want to send drug addicts on MediCal to long-term residential care — like the six-month program at New Bridge — because they say it’s expensive and unnecessary.
Moreover, if the redesign goes through, the federal block grant funding that sustains many providers, including New Bridge, is expected to be repurposed for other substance abuse services. On November 21, the state sent its proposal — named the Drug MediCal Organized Delivery System Waiver — to the US Centers for Medicaid and Medicare Services (CMS). The federal agency is expected to make a decision on the proposal soon.
“The MediCal expansion is the biggest thing we’ve seen in many, many years,” said Renfree, who has worked in the field for fifteen years. The reform will level the playing field, he said, by providing enough resources so that the state can offer the same array and quality of services that was once only available to rich people.
Except, of course, if someone needs long-term residential care.
The drug rehab group at New Bridge comes alive at lunchtime. When I visited the Berkeley facility last fall, nearly sixty residents began talking all at once as they filed into the dining hall. Many of them carried binders and wore buttoned-down shirts and ties. Newcomers, cut slack at first, were easy to spot: They wore sweatpants and oversized T-shirts. As the residents lined up for food, a woman named Sandy yelled above the chatter to say that lunch was BLT sandwiches with three slices of bacon, soup, and salad. “Thank you, Sandy,” they replied in unison.
“New Bridge is often the last stop for folks,” said Angela Porter, who now runs the place. Porter graduated from the program in 1991 and then started working there on and off for the next 24 years. She eventually earned her master’s degree in counseling psychology, and, today, she’s the program director.
Porter explained that many drug addicts have been to numerous different programs before they arrive at New Bridge. Many clients also come from families with long histories of substance abuse and poverty. Some have mental health issues. Often clients end up there by way of the criminal justice system. Like Porter, they choose drug rehab instead of jail.
Long-term rehabs have their own culture. They are like cities of sobriety built upon a regimented-yet-holistic approach to abstinence. “Residential is a little world that goes 24 hours a day,” explained Gavin O’Neill, drug court manger for Alameda County. “It has its own language, its own signs and signifiers, and all these crazy rules.”
Managing a residential program and keeping that world running smoothly takes a lot of resources: therapists, psychologists, psychiatrists, cooks, and drivers, said O’Neill. “No one is getting rich running a residential treatment program,” he said. “They are difficult to staff and there is never enough money.”
O’Neill is an expert. Before he took over the drug court in Oakland, he managed Walden House’s residential drug treatment program for youth in San Francisco for nearly a decade. And before that, he was a heroin addict. At the age of 24, he entered Walden House and spent the next 23 months working in the program. “In general, the people assessed for residential don’t have a lot of basic life skills — they’re like feral cats,” he said. “I needed residential. I needed to be immersed in recovery with no time on my hands. If I had five minutes to think for myself, I was loaded again.”
Long-term residential care’s greatest asset is time. Clients get months to work on themselves. They delve into their past traumas and uncover what issues trigger drug and alcohol use. They also learn basic life skills: waking up early, making their beds, and cleaning their rooms. They learn how to schedule appointments, be responsible, show up for work, and save money. “I felt like I had gotten the rule book that nobody had given me before — the book that told you how other people are living and making it in the world,” O’Neill said. “And that happens in residential.”
However, long-term residential is not suitable for all addicts, advocates say. The strict nature of long-term rehabs can scare people; it’s too intense for them. And research shows that for addicts who still have their jobs, homes, and families — people who haven’t lost it all yet — a less invasive approach can be more effective. “Residential doesn’t work for everybody,” O’Neill said. “I watched a lot of people blow out the door.”
On O’Neill’s desk, in his windowless office inside the Alameda County courthouse in Oakland, is a copy of The American Association of Addictive Medicine Criteria, or simply ASAM. The treatment guidebook has become the go-to text for professionals in the substance abuse field, and it’s the basis of the state’s proposed new system.
“One of things that is attractive about the ASAM to the state is that it is a pretty accurate way to measure somebody’s addiction severity,” O’Neill said. “You don’t want people who are not experts dictating time-based treatments. We need to be flexible in the way we provide treatment.”
O’Neill supports long-term treatment — but only if the client requires that level of care. He also sees the importance of offering a smorgasbord of treatment options for patients, who can then transition between services as their needs change.
The biggest problem with residential rehab is that many people who end up there aren’t diagnosed for that level of care, O’Neill said. He thinks of alcoholism and drug addiction as a disease like cancer or diabetes. If someone thinks they may have cancer, the person doesn’t head straight to the radiologist and get the highest level of radiation possible; rather, a doctor first assesses a patient to see if he or she actually has cancer, and then what type of cancer and how advanced it is. Only then is a treatment plan made. And that is what the ASAM is designed to do for substance abuse.
Under the state’s proposed overhaul, addicts would be able to call a 1-800 number, 24 hours a day, 7 days a week. The phone operator would then direct the person to a local drug treatment provider, where clients will be assessed based on the standard criteria laid out in the ASAM. The provider would then establish a treatment plan based on the individual’s needs. Clients would then move from one level of care to another. A patient could start in short-term residential, and in week move to outpatient services, or vice versa.
The state’s plan calls for all MediCal-funded drug treatment providers to use the ASAM. In addition, all providers that want to bill MediCal will have to get certified. Each county, in turn, will have a choice of whether to participate in the new system. The counties that opt in will have a steady source of funding, but will have to adhere to MediCal rules. Those that opt out will have greater freedom, but less funding and less financial security. People on MediCal won’t have a choice; their treatment will be contingent on the county they live in.
Vitka Eisen, who runs a HealthRIGHT 360 center, a drug treatment provider headquartered in San Francisco, supports the state’s proposal. She called it “really a thoughtful system of care” that will “move California from behind the curve to pretty far ahead of it.” Eisen, like many drug treatment providers, sees the value in residential treatment for addicts who need it. But for her, the benefits of the state’s proposal outweigh the drawbacks. By organizing publicly funded substance abuse services and lifting the MediCal ban (at least on programs that offer no more than ninety days of in-patient treatment), the state’s proposal would allow HealthRIGHT 360 to bill MediCal for most of the nonprofit’s services, Eisen said.
HealthRIGHT 360 formed in 2012, when Walden House and Haight Ashbury Free Clinics merged. It provides numerous services, including long-term residential care, in the Bay Area and Southern California. Eisen agrees with critics of the new approach that capping stays at ninety days isn’t ideal for some of her higher-needs clients, but she said that the proposed plan, with its more robust system of care, represents a major improvement. California’s proposal also allows for a thirty-day extension, in addition to ninety days of residential treatment, for people who need more time.
The state held a handful of meetings last year in order to gain input from service providers and other stakeholders. Karen Baylor, deputy director of the California Department of Health Care Services, Mental Health and Substance Use Disorder Services Division, said the redesign is based on what many professionals in the field told her they wanted. Indeed, numerous substance abuse professionals agreed with the ninety-day cap, she said. She said she was told that 45 days was the average length of stay at rehabs. “We’re not hearing that people need to be in long-term treatment,” she said. “We don’t want residential to be the end of treatment, where you stay there the rest of your life. There is a need for a drug-free environment but discharge planning begins on the day of admission.”
State officials, however, also acknowledge that long-term residential treatment can benefit people who are homeless and caught up in the criminal justice system. However, they consider long-term care to be prohibitively expensive, and believe that if funded, would limit the amount of money that the state could provide for other treatment services.
If the state’s plan is approved, drug and alcohol treatment experts expect the federal block grants that currently fund residential care will no longer do so. Instead, they anticipate that the federal government will repurpose the grants to fund sober living housing.
Sober living isn’t an organized treatment plan; it’s a collection of people in recovery, usually just out of a treatment center, who support each other’s sobriety.
Long-term rehab will continue to exist, but probably only in facilities that are privately funded or are faith-based, like the Salvation Army. If providers such as New Bridge want to continue to offer residential services for more than ninety days, they’ll have to get their respective counties to foot the bill — using non-MediCal dollars. In wealthy San Francisco, treatment providers such as HealthRIGHT360 could have access to county funds earmarked specifically for substance abuse treatment. But for cash-strapped areas like Alameda County, finding the extra funds isn’t likely.
“We have a limited pot of money,” said Manuel Jimenez, director of Alameda County Behavioral Health Care Services, which oversees substance abuse treatment. Jimenez said he could reallocate some of the county funds for residential care, but then he’d have to decrease funding elsewhere. “Whenever a new plan comes out, something else is taken away,” he explained.
As a result, centers such as New Bridge may have to stop offering long-term treatment of more ninety days for most clients — unless they can find new sources of funding.
The one exception, however, is that the state, at least for now, plans to still offer long-term residential care to people who’ve been arrested for substance abuse-related crimes. The Alameda County drug court currently uses state funding to send about thirty people total each year to New Bridge and CURA, a Fremont-based long-term residential provider. But that could change in the coming years as well if the short-term model becomes the state standard for all residential drug treatment.
One option for New Bridge — should the state proposal win approval — would be to place clients in ninety-day residential treatment, and then after that, the clients could move on to a sober living house, attend outpatient day classes, and look for work. Alameda County and state officials want sober living housing to, in effect, replace long-term treatment. Sober living, however, wouldn’t be covered by MediCal. Instead, state and county officials hope that the federal government will repurpose the block grants that currently fund long-term residential and use them to pay for sober living.
Regardless, Porter is determined to continue to offer long-term residential care. She plans to try to raise funding for it — perhaps from New Bridge alumni who understand its value. She also may use the profits from New Bridge’s private-insurance-paid thirty-day program to help finance long-term residential for low-income people.
New Bridge isn’t going anywhere, she said. “No matter what MediCal and the county decide, we will continue our work helping people,” she said. “We will find a way — this is the inherent talent of the addict and the addict in recovery: We always find a way.”
On a February afternoon, inside San Francisco’s Western Addition Public Library, Jimmie Murphy was studying for a test in one of the custodial training courses he’s taking at the City College. He wants to be a janitor and make use of the one marketable skill he learned in state prison. Baby Girl — the pet name of his wife who overdosed on heroin and died years ago — is tattooed on the side of his neck. Last summer, Murphy slept in front of the entrance of this library, underneath the book return slots.
Murphy fits the criteria for long-term residential— homeless, broke, no family, a long history of drug use. He’s working to stay sober by going five days a week to an outpatient drug treatment program at HealthRIGHT 360. At 47, Murphy has been a daily drug and alcohol abuser for most of his life, beginning at the age of 13.
A lifetime of drug use culminated last September 2, when he lurched headfirst into a moving vehicle on Octavia and Market streets in San Francisco. He wanted to die — to stop the voices in his head. Satan and God, he said, were always telling him what to do.
He survived, but most of his teeth were smashed out in the suicide attempt. A few days later, he tried to get into residential rehab, but got waitlisted. Still homeless, he went to outpatient services, hoping a bed would open up. After waiting for three months, Murphy was offered a place to live in a transitional housing unit on Treasure Island — not residential treatment, but a place to live with other sober adults.
Murphy said he’d rather be in residential, in part because it would help him find housing. “Outpatient is for people who are suppose to have their shit together,” Murphy said. Treasure Island is temporary. He still needs to find another place to live.
“I’m scared,” he said. “I’m afraid I won’t be able to deal with life on life’s terms.”
This will be Murphy’s sixth time in an outpatient program. He has been in residential rehab nine times. But this time feels different, he said.
Murphy slung his backpack filled with custodial training literature over his shoulder. Not far from here, he does secretary duties at a twelve-step meeting. He didn’t want to be late.