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California Pays Meth Users To Get Sober

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Angela Hart
Wed, 22 May 2024 09:00:00 +0000

GRASS VALLEY, Calif. — Here in the rugged foothills of California's Sierra Nevada, the streets aren't littered with needles and dealers aren't hustling drugs on the corner.

But meth is almost as easy to come by as a hazy IPA or locally grown weed.

Quinn Coburn knows the lifestyle well. He has used meth most of his adult life, and has done five stints in jail for dealing marijuana, methamphetamine, and heroin. Now 56, Coburn wants to get sober for good, and he says an experimental program through Medi-Cal, California's Medicaid program, which covers low-income people, is helping.

As part of an innovative approach called “contingency management,” Coburn pees in a cup and gets paid for it — as long as the sample is clean of stimulants.

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In the coming fiscal year, the state is expected to allocate $61 million to the experiment, which targets addiction to stimulants such as meth and cocaine. It is part of a broader Medi-Cal initiative called CalAIM, which provides social and behavioral services, including addiction treatment, to some of the state's sickest and most vulnerable patients.

Since April 2023, 19 counties have enrolled a total of about 2,700 patients, including Coburn, according to the state Department of Health Care Services.

“It's that little something that's holding me accountable,” said Coburn, a former construction worker who has tried repeatedly to kick his habit. He is also motivated to stay clean to fight criminal charges for possession of drugs and firearms, which he vociferously denies.

Coburn received $10 for each clean urine test he provided the first week of the program. Participants get a little more money in successive weeks: $11.50 per test in week two, $13 in week three, up to $26.50 per test.

They can earn as much as $599 a year. As of mid-May, Coburn had completed 20 weeks and made $521.50.

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Participants receive at least six months of additional behavioral health treatment after the urine testing ends.

The state has poured significant money and effort into curbing opioid addiction and fentanyl trafficking, but the use of stimulants is also exploding in California. According to the state Department of Health Care Services, the rate of Californians dying from them doubled from 2019 to 2023.

Although the cutting-edge treatment can work for opioids and other drugs, California has prioritized stimulants. To qualify, patients must have moderate to severe stimulant use disorder, which includes symptoms such as strong cravings for the drug and prioritizing it over personal health and well-being.

Substance use experts say incentive programs that reward participants, even in a small way, can have a powerful effect with meth users in particular, and a growing body of evidence indicates they can lead to long-term abstinence.

“The way stimulants work on the brain is different than how opiates or alcohol works on the brain,” said John Duff, lead program director at Common Goals, an outpatient drug and alcohol counseling center in Grass Valley, where Coburn receives treatment.

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“The reward system in the brain is more activated with amphetamine users, so getting $10 or $20 at a time is more enticing than sitting in group therapy,” Duff said.

Duff acknowledged he was skeptical of the multimillion-dollar price tag for an experimental program. “You're talking about a lot of money,” he said. “It was a hard sell.”

What convinced him? “People are showing up, consistently. To get off stimulants, it's proving to be very effective.”

California was the first state to cover this approach as a benefit in its Medicaid program, according to the Department of Health Care Services, though other states have since followed, including Montana.

Participants in Nevada County must show up twice a week to provide a urine sample, tapering to once a week for the second half of treatment. Every time the sample is free of stimulants, they get paid via a retail gift card — even if the sample is positive for other kinds of drugs, including opioids.

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Though participants can collect the money after each clean test, many opt for a lump sum after completing the 24-week program, Duff said. They can choose gift cards from companies such as Walmart, Bath & Body Works, Petco, Subway, and Hotels.com.

Charlie Abernathybettis — Coburn's substance use disorder counselor, who helps run the program for Nevada County — said not everyone consistently produces a clean urine test, and he has devised a system to stop people from rigging their results.

For example, he uses blue toilet cleaner to prevent patients from watering down their urine, and has dismantled a spigot on the bathroom faucet to keep them from using warm water for the same purpose.

If participants fail, there are no consequences. They simply don't get paid that day, and can show up and try again.

“We aren't going to change behavior by penalizing people for their addiction,” Abernathybettis said, noting the ultimate goal is to transition participants into long-term treatment. “Hopefully you feel comfortable here and I can convince you to sign up for outpatient treatment.”

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Abernathybettis has employed a tough love approach to addiction therapy that has helped keep Coburn sober and accountable since he started in January. “It's different this time,” Coburn said as he lit a cigarette on a sunny afternoon in April. “I have support now. I know my life is on the line.”

Growing up in the Bay Area, Coburn never quite felt like he fit in. He was adopted at an early age and dropped out of high school. His erratic home life set him on a course of hard drug use and crime, including manufacturing and selling drugs, he said.

“When I first did crank, it made me feel like I was human for the first time. All my phobias about being antisocial left me,” Coburn said, using a street name for meth.

Coburn escaped to the solitude of the mountains, trees, and rivers that define the rural landscape in Grass Valley, but the area was also rife with drugs.

Construction accidents in 2012 left him in excruciating pain — and unable to work.

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Coburn fell deeper into the drug scene, as both a user and a manufacturer. “You wouldn't believe the market up here for it — more than you can even imagine,” he said. “It's not an excuse, but I had no way to make a living.”

Financially strapped, he rented a cheap, converted garage from another local drug dealer, he said. Law enforcement officers raided the house in October, and authorities found a gun and large amounts of fentanyl and heroin. Coburn, who faces up to 30 years in prison, vigorously defends himself, saying the drugs and weapons were not his. “All the other ones I did. Not this one,” he said.

Coburn is also in an outpatient addiction program and is active in Alcoholics Anonymous, sometimes attending multiple meetings a day.

Every week, the small payments from the Medi-Cal experiment feel like small wins, he said.

He is planning to take his $599 as a lump sum and give it to his foster parents, with whom he is living as he fights his criminal charges.

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“It's the least I can do for them letting me stay with them and get better,” Coburn said, choking back tears. “I'm not giving up.”

This article is part of “Faces of Medi-Cal,” a California Healthline series exploring the impact of the state's safety-net health program on enrollees.

This article was produced by KFF Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation. 

——————————
By: Angela Hart
Title: California Pays Meth Users To Get Sober
Sourced From: kffhealthnews.org//article/california-pays-meth-users-sober-contingency-management-calaim/
Published Date: Wed, 22 May 2024 09:00:00 +0000

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Funding Instability Plagues Program That Brings Docs to Underserved Areas

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Michelle Andrews
Thu, 13 Jun 2024 09:00:00 +0000

For Diana Perez, a medical resident at the Family Center of Harlem, the handwritten thank-you note she received from a patient is all the evidence she needs that she has chosen the right training path.

Perez helped the patient, a homeless, West African immigrant who has HIV and other chronic conditions, get the medications and care he needed. She also did the paperwork that documented his medical needs for the nonprofit that helped him apply for asylum and secure housing.

“I really like whole-person care,” said Perez, 31, who has been based at this New York City health center for most of the past three years. “I wanted to learn and train, dealing with the everyday things I will be seeing as a primary care physician and really immersing myself in the community,” she said.

Few primary care residents get such extensive community-based outpatient training. The vast majority spend most of their residencies in hospitals. But Perez, who is being trained through the Teaching Health Center Graduate Medical Education program, is among those treating patients in federally qualified health centers and community clinics in medically underserved rural and urban areas around the country. After graduating, these residents are more likely than hospital-trained graduates to stay on and practice locally where they are often desperately needed, research has found.

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Amid the long-term shift from inpatient to outpatient medical care, training primary care doctors in outpatient clinics rather than hospitals is a no-brainer, according to Robert Schiller, chief academic officer at the Institute for Family Health, which runs the Harlem THC program and operates dozens of other health center sites in New York. “Care is moving out into the community,” he said, and the THC program is “creating a community-based training environment, and the community is the classroom.”

Yet because the program, established under the 2010 Affordable Care Act, relies on congressional appropriations for funding, it routinely faces financial uncertainty. Despite bipartisan support, it will run out of funds at the end of December unless lawmakers vote to replenish its coffers — no easy task in the current divided Congress in which gaining passage for any type of legislation has proved difficult. Faced with the prospect of not being able to cover three years of residency training, several of the 82 THC programs nationwide recently put their residency training programs on hold or are phasing them out.

That's what the DePaul Family and Social Medicine Residency Program in New Orleans East, an area that has been slow to recover after Hurricane Katrina in 2005, has done. With a startup grant from the federal Health Resources and Services Administration, the community health center hired staff for the residency program and became accredited last fall. They interviewed more than 50 medical students for residency slots and hoped to enroll their first class of four first-year residents in July. But with funding uncertain, they put the new program on hold this spring, a few weeks before “Match Day,” when residency programs and students are paired.

“It was incredibly disappointing for many reasons,” said Coleman Pratt, the residency program's director, who was hired two years ago to launch the initiative.

Until we know we've got funding, we're “treading water,” Pratt said.

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“In order to have eligible applications in-hand should Congress appropriate new multi-year funds, HRSA will issue a Notice of Funding Opportunity in late summer for both new and expanded programs to apply to be funded in FY 2025, subject to the availability of appropriations,” said Martin Kramer, an HRSA spokesperson, in an email.

For now, the Teaching Health Center program has $215 million to spend through 2024.

By contrast, the Centers for Medicare & Medicaid Services paid hospitals $18 billion to provide residency training for doctors in primary care and other specialties. Unlike THC funding, which must be appropriated by Congress, Medicare graduate medical education funding is guaranteed as a federal entitlement program.

Trying to keep THC's three-year residency programs afloat when congressional funding comes through in fits and starts weighs heavily on the facilities trying to participate. These pressures are now coming to a head.

“Precariousness of funding is a theme,” said Schiller, noting that the Institute for Family Health put its own plans for a new THC in Brooklyn on hold this year.

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The misalignment between the health care needs of the American population and the hospital-based medical training most doctors receive is a long-recognized problem. A 2014 report by the National Academies Press noted that “although the GME system has been producing more physicians, it has not produced an increasing proportion of physicians who choose to practice primary care, to provide care to underserved populations, or to locate in rural or other underserved areas.”

The Teaching Health Center program has demonstrated success in these areas, with program graduates more likely to practice in medically underserved areas after graduation. According to a study that analyzed the practice patterns of family medicine graduates from traditional GME training programs vs. those who participated in the THC program, nearly twice as many THC graduates were practicing in underserved areas three years after graduating, 35.2% vs. 18.6%. In addition, THC graduates were significantly more likely to practice in rural areas, 17.9% vs. 11.8%. They were also more likely to provide substance use treatment, behavioral health care, and outpatient gynecological care than graduates from regular GME programs.

But the lack of reliable, long-term funding is a hurdle to the THC training model's potential, proponents say. For 2024, the Biden administration had proposed three years of mandatory funding, totaling $841 million, to support more than 2,000 residents.

“HRSA is eager to fund new programs and more residents, which is why the President's Budget has proposed multi-year increased funding for the Teaching Health Center program,” Kramer said in an email.

The American Hospital Association supports expanding the THC program “to help address general workforce challenges,” said spokesperson Sharon Cohen in an email.

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The program appeals to residents interested in pursuing primary and community care in underserved areas.

“There's definitely a selection bias in who chooses these [THC] programs,” said Candice Chen, an associate professor of health policy and management at George Washington University.

Hospital primary care programs, for instance, typically fail to fill their primary care residency slots on Match Day. But in the THC program, “every single year, all of the slots match,” said Cristine Serrano, executive director of the American Association of Teaching Health Centers. On Match Day in March, more than 19,000 primary care positions were available; roughly 300 of those were THC positions.

Amanda Fernandez, 30, always wanted to work with medically underserved patients. She did her family medicine residency training at a THC in Hendersonville, North Carolina. She liked it so much that, after graduating last year, the Miami native took a job in Sylva, about 60 miles away.

Her mostly rural patients are accustomed to feeling like a way station for physicians, who often decamp to bigger metro areas after a few years. But she and her husband, a physician who works at the nearby Cherokee Indian Hospital, bought a house and plan to stay.

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“That's why I loved the THC model,” Fernandez said. “You end up practicing in a community similar to the one that you trained in.”

——————————
By: Michelle Andrews
Title: Funding Instability Plagues Program That Brings Docs to Underserved Areas
Sourced From: kffhealthnews.org//article/physician-teaching-health-centers-funding-instability-underserved-areas/
Published Date: Thu, 13 Jun 2024 09:00:00 +0000

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Watch: California Pays Drug Users To Stay Clean

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Thu, 13 Jun 2024 09:00:00 +0000

KFF senior correspondent Angela Hart appeared on Spectrum News 1's “LA Times Today” last week to explain how California is trying to help hard-drug users kick their habit by paying them to stay clean.

California was the first state to expand access to this cutting-edge addiction treatment, called “contingency management,” in its Medicaid program. Washington and Montana have since followed.

California is focusing on stimulants like meth and cocaine. Under the program, participants must pee into a cup regularly, and if the urine is free of stimulants, they get paid with a gift card, starting at $10 for the first test. The longer they abstain, the more they're paid — up to $599 a year.

Click here to watch Hart discuss the treatment on “LA Times Today.”

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You can read Hart's in-depth article about California's initiative. She also wrote about national efforts to encourage other states to adopt the novel approach.

This article was produced by KFF Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation. 

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Title: Watch: California Pays Drug Users To Stay Clean
Sourced From: kffhealthnews.org/news/article/california-pays-drug-users-to-stay-clean-broadcast-appearance/
Published Date: Thu, 13 Jun 2024 09:00:00 +0000

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Biden’s on Target About What Repealing ACA Would Mean for Preexisting Condition Protections

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Jacob Gardenswartz
Thu, 13 Jun 2024 09:00:00 +0000

If the Affordable Care Act were terminated, “that would mean over a hundred million Americans will lose protections for preexisting conditions.”

President Joe Biden in a campaign advertisement, May 8

President Joe Biden's reelection campaign wants voters to contrast his record on care policy with his predecessor's. In May, Biden's campaign began airing a monthlong, $14 million ad campaign targeting swing-state voters and minority groups with spots on TV, digital, and radio.

In the ad, titled “Terminate,” Biden assails former President Donald Trump for his past promises to overturn the Affordable Care Act, also known as Obamacare. Biden also warns of the potential effect if Trump is returned to office and again pursues repeal.

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“That would mean over a hundred million Americans will lose protections for preexisting conditions,” Biden said in the ad.

Less than six months from Election Day, polls show Trump narrowly leading Biden in a head-to-head race in most swing states. And voters trust Trump to better handle issues such as inflation, crime, and the economy by significant margins.

An ABC News/Ipsos poll of about 2,200 adults, released in early May, shows the only major policy issues on which Biden received higher marks than Trump were health care and abortion access. It's no surprise, then, that the campaign is making those topics central to Biden's pitch to voters.

As such, we dug into the facts surrounding Biden's claim.

Preexisting Condition Calculations

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The idea that 100 million Americans are living with one or more preexisting conditions is not new. It was the subject of a back-and-forth between then-candidate Biden and then-President Trump during their previous race, in 2020. After Biden cited that statistic in a presidential debate, Trump responded, “There aren't a hundred million people with preexisting conditions.”

A KFF /PolitiFact HealthCheck at the time rated Biden's claim to be “mostly true,” finding a fairly large range of estimates — from 54 million to 135 million — of the number of Americans with preexisting conditions. Estimates on the lower end tend to consider “preexisting conditions” to be more severe chronic conditions such as cancer or cystic fibrosis. Estimates at the spectrum's higher end include people with more common health problems such as asthma and obesity, and behavioral health disorders such as substance use disorder or depression.

Biden's May ad focuses on how many people would be vulnerable if protections for people with preexisting conditions were lost. This is a matter of some debate. To understand it, we need to break down the protections put in place by the ACA, and those that exist separately.

Before and After

Before the ACA's preexisting condition protections took effect in 2014, insurers in the individual market — people buying coverage for themselves or their families — could charge higher premiums to people with particular conditions, restrict coverage of specific procedures or medications, set annual and lifetime coverage limits on benefits, or deny people coverage.

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“There were a number of practices used by insurance companies to essentially protect themselves from the costs associated with people who have preexisting conditions,” said Sabrina Corlette, a co-director of the Center on Health Insurance Reforms at Georgetown University and an expert on the health insurance marketplace.

Insurers providing coverage to large employers could impose long waiting periods before employees' benefits kicked in. And though employer-sponsored plans couldn't discriminate against individual employees based on their health conditions, small-group plans for businesses with fewer than 50 employees could raise costs across the board if large numbers of employees in a given company had such conditions. That could prompt some employers to stop offering coverage.

“The insurer would say, ‘Well, because you have three people with cancer, we are going to raise your premium dramatically,' and therefore make it hard for the small employer to continue to offer coverage to its workers because the coverage is simply unaffordable,” recalled Edwin Park, a research professor at Georgetown University's McCourt School of Public Policy who researches public health insurance markets.

As a result, many people with preexisting conditions experienced what some researchers dubbed “job lock.” People felt trapped in their jobs because they feared they wouldn't be able to get health insurance anywhere else.

Some basic preexisting condition protections exist independent of the ACA. The 1996 Health Insurance Portability and Accountability Act, for example, restricted how insurers could limit coverage and mandated that employer-sponsored group plans can't refuse to cover someone because of a health condition. Medicare and Medicaid similarly can't deny coverage based on health background, though age and income-based eligibility requirements mean many Americans don't qualify for that coverage.

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Once the ACA's preexisting condition protections kicked in, plans sold on the individual market had to provide a comprehensive package of benefits to all purchasers, no matter their health status.

Still, some conservatives say Biden's claim overstates how many people are affected by Obamacare protections.

Even if you consider the broadest definition of the number of Americans living with such conditions, “there is zero way you could justify that 100 million people would lose coverage” without ACA protections, said Theo Merkel, who was a Trump administration health policy adviser and is now a senior research fellow with the Paragon Health Institute and a senior fellow at the Manhattan Institute for Policy Research, a conservative think tank.

Joseph Antos, a senior fellow at the American Enterprise Institute, a conservative think tank, called the ad's preexisting conditions claim “the usual bluster.” To reach 100 million people affected, he said, “you have to assume that a large number of people would lose coverage.” And that's unlikely to happen, he said.

That's because most people — about 55% of Americans, according to the most recent government data — receive health insurance through their employers. As such, they're protected by the Health Insurance Portability and Accountability Act rules, and their plans likely wouldn't change, at least in the short term, if the ACA went away.

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Antos said major insurance companies, which have operated under the ACA for more than a decade, would likely maintain the status quo even without such protections. “The negative publicity would be amazing,” he said.

People who lose their jobs, he said, would be vulnerable.

But Corlette argued that losing ACA protections could lead to Americans being priced out of their plans, as health insurers again begin medical underwriting in the individual market.

Park predicted that many businesses could also gradually find themselves priced out of their policies.

“For those firms with older, less healthy workers than other small employers, they would see their premiums rise,” he told KFF Health .

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Moreover, Park said, anytime people lost work or switched jobs, they'd risk losing their insurance, reverting to the old days of job lock.

“In any given year, the number [of people affected] will be much smaller than the 100 million, but all of those 100 million would be at risk of being discriminated against because of their preexisting condition,” Park said.

Our Ruling

We previously ruled Biden's claim that 100 million Americans have preexisting conditions as in the ballpark, and nothing suggests that's changed. Depending on the definition, the number could be smaller, but it also could be even greater and is likely to have increased since 2014.

Though Biden's claim about the number of people who would be affected if those protections went away seems accurate, it is unclear how a return to the pre-ACA situation would manifest.

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On the campaign trail this year, Trump has promised — as he did many times in the past — to replace the health law with something better. But he's never produced a replacement plan. Biden's claim shouldn't be judged based on his lack of specificity.

We rate Biden's claim Mostly True.

our sources

ABC News/Ipsos Poll, “Six Months Out, a Tight Presidential Race With a Battle Between Issues & Attributes,” May 5, 2024

Avalere, “Repeal of ACA's Pre-Existing Condition Protections Could Affect Health Security of Over 100 Million People,” Oct. 23, 2018

Biden-Harris 2024 campaign email, “NEW AD: Biden-Harris 2024 Launches ‘Terminate' Slamming Trump for Attacks on Health Care,” May 8, 2024

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Center for American Progress, “Number of Americans With Preexisting Conditions by District for the 116th Congress,” Oct. 2, 2019

Census Bureau, “Health Insurance Coverage in the United States: 2022,” September 2023

CNN, “Trump Administration Gives States New Power to Weaken Obamacare,” Oct. 22, 2018

Department of Health and Human Services, “Health Insurance Coverage for Americans with Pre-Existing Conditions: The Impact of the Affordable Care Act,” Jan. 5, 2017

Department of Health and Human Services, “The Health Insurance Portability and Accountability Act (HIPAA) of 1996 Helpful Tips,” accessed May 15, 2024

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Email exchanges with Biden-Harris 2024 campaign official, May 13-15, 2024

Email exchange with Karoline Leavitt, Trump 2024 campaign national press secretary, May 13, 2024

KFF, “KFF Health Tracking Poll: The Public's Views on the ACA,” May 15, 2024

KFF, “Recent Trends in Mental Health and Substance Use Concerns Among Adolescents,” Feb. 6, 2024

KFF Health News, “Drowning in a ‘High-Risk Insurance Pool' — At $18,000 a Year,” Feb. 27, 2017

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KFF Health News and PolitiFact, “Biden's in the Ballpark on How Many People Have Preexisting Conditions,” Oct. 1, 2020

The New York Times, “Trump Leads in 5 Key States, as Young and Nonwhite Voters Express Discontent With Biden,” May 13, 2024

Phone interview and email exchanges with Theo Merkel, a senior fellow at the Manhattan Institute and the director of the Private Health Reform Initiative at the Paragon Health Institute, May 14-15, 2024

Phone interview with Edwin Park, a research professor at Georgetown University's McCourt School of Public Policy, May 22, 2024

Phone interview with Sabrina Corlette, a co-director of the Center on Health Insurance Reforms at Georgetown University, May 14, 2024

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Truthsocial.com, post by @realDonaldTrump, Nov. 25, 2023

The Wall Street Journal, “Healthcare.gov to Shut Down During Parts of Enrollment Period for Maintenance,” Sept. 23, 2017

Work, Aging and Retirement, “Job Lock, Work, and Psychological Well-Being in the United States,” Feb. 19, 2016

YouTube.com/@CSPAN, “First 2020 Presidential Debate between Donald Trump and Joe Biden,” Sept. 29, 2020

YouTube.com/@JoeBiden, “Terminate” campaign advertisement, May 10, 2024

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Phone interview with Joseph Antos, a senior fellow at the American Enterprise Institute, June 5, 2024

Health Affairs, What It Means To Cover Preexisting Conditions, Sept. 11, 2020

KFF, Pre-Existing Conditions and Medical Underwriting in the Individual Insurance Market Prior to the ACA, Dec. 12, 2016

PolitiFact, “Does Trump Want To Repeal the ACA, as Biden Says? Tracking His Changing Stance Over the Years,” June 3, 2024

——————————
By: Jacob Gardenswartz
Title: Biden's on Target About What Repealing ACA Would Mean for Preexisting Condition Protections
Sourced From: kffhealthnews.org/news/article/fact-check-biden-campaign-ad-repealing-obamacare-preexisting-conditions/
Published Date: Thu, 13 Jun 2024 09:00:00 +0000

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