Voters are being asked whether California should increase accountability in the 340B drug discount program, which provides money for community clinics, safety net hospitals and other nonprofit health-care providers.

The program requires pharmaceutical companies to give drug discounts to these clinics and nonprofit entities, which can bank revenue by charging higher reimbursement rates.

Advocates pushing the measure, Proposition 34, say some entities are using the drug discount program as a slush fund, plowing money into housing and homelessness initiatives that don’t meet basic patient safety standards. Researchers and advocates have called for greater oversight.

“There are 340B entities that are misusing these public dollars,” said Nathan Click, a spokesperson for the pro-Proposition 34 campaign. “The whole point of this program is to use this money to get more low-income people health-care services.”

The initiative wouldn’t bar 340B providers from using health-care funds for housing or homelessness programs. Instead, it targets providers that spend more than $100 million on purposes other than direct patient care over 10 years. It would mandate that 98 percentof 340B revenues go to direct patient care. It also targets 340B providers with health insurer contracts and pharmacy licenses and those serving low-income Medicaid or Medicare patients that have been dinged with at least 500 high-severity housing violations for substandard or unsafe conditions.

That has placed a bull’s eye on the Los Angeles-based AIDS Healthcare Foundation, a nonprofit that provides direct patient care via clinics and pharmacies in California and other states, including Illinois, Texas and New York. It also owns housing for low-income and homeless people.

A Los Angeles Times investigation found that many residents of AIDS Healthcare Foundation properties are living in deplorable, unhealthy conditions.

Michael Weinstein, the foundation’s president, disputes those claims and argues that Proposition 34 proponents, including real estate interests, are going after him for another ballot initiative that seeks to implement rent control in more communities across California.

“It’s a revenge initiative,” Weinstein said, arguing that the deep-pocketed California Apartment Association is targeting his foundation — and its health and housing operations — because it has backed ballot measures pushing rent control across California. “This is a two-pronged attack against us to defeat rent control.”

Weinstein is locked in a feud with the apartment association, the chief sponsor of the initiative, which has contributed handsomely to pass Proposition 34. Opponents argue that the initiative is “a wolf in sheep’s clothing.”

Weinstein acknowledged to KFF Health News that his nonprofit uses money from 340B drug discounts to support its housing initiatives but argued they are helping treat and house some of the most vulnerable people, who would otherwise be homeless.

The apartment association declined several requests for comment. But Proposition 34 backers say they aren’t going after rent control — or Weinstein and his nonprofit.

Supporters argue that “rising health care costs are squeezing millions of Californians” and say that the initiative would “give California patients and taxpayers much needed relief, and lowers state drug costs, while saving California taxpayers billions.”

If the initiative passes and 340B providers do not spend 98 percent of the revenue on direct patient care, they could lose their license to practice health care and their nonprofit status.

This article is not available for syndication due to republishing restrictions. If you have questions about the availability of this or other content for republication, please contact NewsWeb@kff.org.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

USE OUR CONTENT

This story can be republished for free (details).

Officers gave him a choice: Go to a shelter or get arrested and cited for sleeping outside.

Douglass was trying to figure out what to do as he dismantled his tent. If he accepted temporary shelter, he’d risk missing an important appointment with his street medicine case manager, who was due to meet him at his tent in the morning to help him secure a low-income housing unit with wraparound services — and he worried about losing his medications, ID, and other vital documents again in another homeless sweep.

Douglass, who didn’t have a working cellphone, knew if he moved from where he’d slept for months, his case manager might not be able to find him. “I’m so close to getting housing. I need to be here tomorrow morning so I can try and get inside,” he said, trying to reason with officers as he was handcuffed and arrested for illegal lodging.

California, the epicenter of the U.S. homelessness crisis, is cracking down on people living outside like never before, taking an aggressive new stance to dismantling and clearing homeless encampments in the wake of a watershed U.S. Supreme Court ruling in late June that makes it easier for government agencies to fine and arrest people for living on streets and sidewalks, in broken-down vehicles, or within public parks — even if there is no shelter or housing available. From San Francisco to Los Angeles, communities are launching cleanup operations, ratcheting up enforcement of existing anticamping laws, and, in some places, passing new laws to try to prevent people from living outdoors.

On the ground, health care experts and homeless service providers say the law enforcement crackdown is undercutting taxpayer investments in evidence-based treatment and housing services that are being deployed by cities and states around the nation as politicians look to the health care system to aggressively move people off the streets.

The sweeps — which have taken off under Democratic Gov. Gavin Newsom, who issued an executive order in late July requiring state agencies to remove encampments and encouraging local governments to do the same — have unleashed chaos for homeless people and are breaking crucial connections with health care providers, social service agencies, and housing navigators trying to help them get healthy and off the streets.

Newsom’s hard-line stance is undermining his signature Medicaid initiative, known as CalAIM, which dedicates $12 billion over five years in part to helping homeless people receive health care, housing, and social services. The experimental program, meant to stabilize the most vulnerable and keep low-income patients out of costly institutional care in hospitals, jails, and nursing homes, for instance, launched in early 2022 with backing from the Biden administration, and provides state and national health care funding to street medicine teams, hospitals, health insurance companies, community clinics, and other organizations to serve homeless people.

It comes as Newsom announced this month that his health secretary, Mark Ghaly, who has spearheaded the state’s infusion of social services for homeless people into the health care system, would be stepping down.

Encampment clearings are also upheaving long-standing federal health policies that provide billions of dollars each year to street medicine providers, case management teams, and front-line community clinic workers, including through the national “Health Care for the Homeless” program, which is also aimed at helping homeless people get healthy and navigate a path to permanent housing.

Newsom has been emphatic that streets are not a home and that it’s unsafe to let people live outside amid public health hazards like rats, drug needles, and piles of trash. The second-term governor, who has threatened to withhold homelessness funding from communities that fail to show enough progress, argues that his policies are helping get people long-term housing and services.

“There are simply no more excuses,” Newsom said in July.

Health care providers and homelessness experts say the result is a slow-moving health care catastrophe instigated by the very Democratic politicians touting the need for care and services around California, home to more homeless people than any other state in the nation.

No place is going as hard as San Francisco, a fiercely liberal city that has long embraced its reputation as a place where homeless people could find refuge and robust services.

Now, case managers, housing navigators, and street medicine teams say vulnerable people are growing sicker amid the crackdown and that many of their patients have simply disappeared. Others have lost medications and critical documents like birth certificates and Social Security cards, setting back efforts to stabilize people with housing, mental health services, and addiction treatment. Front-line providers here say the city has become a glaring example of homelessness policy gone wrong.

“All the sweeps and arrests are doing is moving people to the next sidewalk and disrupting their continuity of care. It’s a huge waste of resources,” said Shannon Heuklom, a primary care provider and an expert in street medicine for the San Francisco Community Health Center, with a clinic nestled in the heart of the Tenderloin.

“Some portion of folks may end up in a shelter, but for the most part the city is just moving them all around and making them more unwell, making their mental health worse, making their physical health worse,” she said.

Disrupted Care

In the Tenderloin, Douglass was frantic. Police told him and his wife, Jasmine Byron, and another partner, Christina Richardson, that they could avoid arrest if they went into a massive congregate shelter. But they’d have to sacrifice most of their stuff, taking just two bags each. They’d already lost lifesaving medications, including for epilepsy, in a previous camp clearing. And Douglass had finally replaced his ID and asthma medication; he didn’t want more stuff thrown away amid the chaos.

On this early August morning, Douglass opted to stay with his belongings. The trio are part of about 70 homeless arrests in San Francisco since the city’s mayor, London Breed, ratcheted up cleanup operations in the beginning of August following the Supreme Court’s decision in late June, according to San Francisco Police Department spokesperson Evan Sernoffsky.

“We’re here to enforce the law,” said Lt. Wayman Young, one of the five officers. “We get a lot of complaints: People can’t use the sidewalk; there’s a lot of garbage.”

As the three were separated and cuffed, a woman driving by stuck her hands out her window and clapped, cheering the sidewalk arrest and yelled “Thank you!” A passerby in a wheelchair averted the tense standoff by rolling into a traffic lane, dodging vehicles as he looked for a vacant section of sidewalk to use.

Douglass missed his housing appointment the morning after his arrest, confirmed his street medicine case manager, Justin Jackson from the San Francisco Community Health Center. Amid his tossed belongings were his ID card, which is required to get into housing, so he was back in line at the clinic the next day filling out a Department of Motor Vehicles voucher form to replace it for free.

Because Douglass is homeless and on Medi-Cal, California’s version of Medicaid, he is eligible for CalAIM services that assist homeless patients with finding a permanent place to live, as well as helping to cover security deposits and utility bills. CalAIM also offers eviction prevention support, and next year California is expected to add a new Medi-Cal benefit providing up to six months of free rent or temporary housing.

But with his documents thrown away, his eligibility for housing was delayed.

Front-line workers are now spending immense time and resources helping people replace valuables like medications, Social Security cards, and birth certificates lost due to sweeps. They notice patients are skipping routine health care and spot an uptick in drug use, anxiety, and depression.

“This is just making homelessness worse,” said Evelyn Peña, a CalAIM care manager at the Mission Neighborhood Health Center in San Francisco.

Taylor Cuffaro, a nurse practitioner and street medicine provider with the San Francisco Community Health Center, trudged the streets of the Tenderloin with Eli Benway, a licensed clinical social worker who provides talk therapy and other behavioral health treatment on the street, searching for patients on a bright August afternoon.

Some needed help managing chronic diseases and mental health conditions. Others were due for antipsychotic injectables that last longer than pill medications. Some needed refills of HIV medications.

“Health insurance companies aren’t just going to give you more medication,” Cuffaro said. “That’s not how it works, so people really are at risk of dying faster.”

Part of what’s being squandered is trust, which is vital for getting people off the streets. “These sweeps are just making our job impossible,” Cuffaro said, searching unsuccessfully for a patient in an alley.

Politics of Homelessness

The statewide crackdown is playing out despite a growing body of evidence showing that providing robust health care, along with social services and intensive case management, can effectively move homeless people off the streets and improve health, while also saving taxpayer and health care spending on costly institutional care.

Democrats are embracing a get-tough approach as public patience wears thin over the intractable crisis. Newsom’s stance is not entirely new: During his tenure as San Francisco mayor, from 2004 to 2011, he spearheaded controversial homelessness ideas, including an ordinance known as sit/lie, which made it illegal to sit or lie on public sidewalks.

Newsom and local leaders, including Breed, say they must balance ensuring public safety and clean streets with a humane approach to clearing camps, while trying to get people indoors. Breed administration officials argue that while some homeless people do accept shelter, many are opting to stay on the streets while declining treatment.

“People won’t accept shelter, and they won’t follow up on their medical care or behavioral health treatment or any of that, often because they need to stay and monitor their belongings, some of which are totally soiled and becoming a health hazard,” said David Nakanishi, a clinical social worker who heads the Breed administration’s Healthy Streets Operation Center, which spearheads the sweeps.

In Los Angeles, meanwhile, street medicine provider Brett Feldman is losing his patients amid the sweeps. “It really undermines our housing efforts,” he said.

A city report released in May found that clearing camps and enforcing anticamping laws that ban people from sleeping, sitting, or keeping belongings on sidewalks in certain sensitive areas, including school zones, parks, or freeway underpasses, is not effectively helping people into housing. After spending roughly $3 million enforcing anticamping laws from 2021 to 2023, the report found, the city placed just two people into permanent housing and 81% of encampment sites have been repopulated.

In one central Los Angeles district where law enforcement is not aggressively enforcing anticamping laws, street homelessness fell roughly 38% in a one-year period from 2023 to 2024, said Indu Subaiya, interim CEO for the nonprofit Healthcare in Action, which has been housing and treating patients there.

“We’re starting to actually see results and reductions in unsheltered homelessness,” Subaiya said. “However, in Southern California counties aggressively enforcing Newsom’s executive order and clearing encampments, we’re seeing our patients and their medical conditions set back profoundly.”

Once Douglass was released, he was back in the Tenderloin hunting for housing and popping his tent up the street from his previous hangout.

“Every time I try to get my documents to get housing, I get knocked backwards,” he said. “I guess the city thinks we all need to be in handcuffs.”

By the next morning, the encampment had grown twice in size.

Healthbeat is a nonprofit newsroom covering public health published by Civic News Company and KFF Health News. Sign up for its newsletters here.

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

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

USE OUR CONTENT

This story can be republished for free (details).

And it’s actually making money.

Sachin Jain, who worked on federal Medicaid policy during his tenure in the Obama administration, helped spearhead a Southern California-based street medicine group called Healthcare in Action in 2021 — and makes no bones about wanting to capture new money from the state and federal governments to treat and house homeless people.

“Health-care issues cause homelessness, but they are also exacerbated by homelessness,” Jain told me. “And the dollars in health care are enormous.”

Around the country, Jain and street medicine doctors and nurses — who have long practiced on the fringes of the health-care system with little revenue — are becoming integral players in the Biden administration’s effort to address the consequences of homelessness.

No longer reliant on inconsistent funding and charitable giving, many street medicine operations are taking advantage of billions in Medicaid dollars to provide social services, from helping patients find an apartment to paying their utility bills. Since October, the federal government has also boosted reimbursements for providers caring for homeless people in the field.

“We’re being brought into the insurance world, and we’re eligible for reimbursement now,” said Jim Withers, a longtime street medicine provider in Pittsburgh who helped start the movement. “We’re legit!”

But Withers is wary of the moneymaking endeavors popping up to treat homeless people.

“I do worry about the corporatization of street medicine and capitalism invading what we’ve been building,” he said. “Caring for people under bridges and on the streets does not always align with the economics of our health-care system. The spirit of the street medicine movement has been one of social justice, but nobody owns the streets.”

California is an ideal laboratory for this new world of Medicaid-funded social services. It is home to more people living on streets and sidewalks, in vehicles, or along waterways than any other state. It is also home to more street medicine providers than anywhere else: 64 of the roughly 150 street medicine organizations across the country are here.

Healthcare in Action employs doctors, nurses and social workers who deliver a range of medical services, including basic wound care, medication administration and antipsychotic injections.

Its street medicine teams operate in 17 California communities and revenue are soaring, reaching $15.4 million in 2023, up from $2 million in 2021. It makes money from Medicaid and charitable contributions, among other sources. It also contracts with hospitals, health insurance companies and municipalities to provide services.

Jain says Healthcare in Action addresses sickness on the streets and saves the health system money by keeping homeless people with costly conditions out of hospitals and jails.

His street medicine teams also work to get people food, addiction treatment and, in some cases, housing.

But much of the teams’ time and energy is dedicated to building trust. It can take time to persuade people to agree to medical care, or housing, for that matter.

“One of the challenges in health care is we dehumanize people who experience homelessness,” Jain said. “We see them as not as worthy of the courtesies that the rest of us have.”

This article is not available for syndication due to republishing restrictions. If you have questions about the availability of this or other content for republication, please contact NewsWeb@kff.org.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

USE OUR CONTENT

This story can be republished for free (details).

Estos médicos, enfermeros y trabajadores sociales se están desplegando en las calles de Los Ángeles para ofrecer atención médica y servicios sociales a las personas sin hogar: soldados de un nuevo modelo de negocio que está arraigándose en comunidades de toda California.

Su estrategia: construir confianza con las personas sin hogar para darles medicinas dondequiera que estén… y ganar dinero haciéndolo.

“La mayor población de personas sin hogar en este país está aquí en el sur de California”, dijo Sachin Jain, ex funcionario de salud de la administración Obama que es CEO de SCAN Group, que dirige un plan de Medicare Advantage que cubre a unas 300,000 personas en California, Arizona, Nevada, Texas y Nuevo México.

“El segmento de más rápido crecimiento de personas que experimentan la falta de vivienda son en realidad los adultos mayores”, dijo. “Dije, ‘Tenemos que hacer algo al respecto'”.

La organización de Jain creó hace tres años Healthcare in Action, un grupo médico que envía a los practicantes a las calles de California exclusivamente para atender a personas sin hogar. Ha crecido rápidamente, estableciendo operaciones en 17 comunidades, incluyendo Long Beach, West Hollywood y el condado de San Bernardino.

Desde su lanzamiento, Healthcare in Action ha atendido a unos 6,700 pacientes sin techo y ha realizado aproximadamente 77,000 diagnósticos, desde esquizofrenia hasta diabetes. Ha puesto a unas 300 personas en viviendas permanentes o temporales.

En la mayor parte del país, la medicina de calle o callejera se practica como una labor caritativa, dirigida a servir a una población de pacientes compleja que ha sido desatendida por la medicina tradicional, dicen sus defensores.

Llevando vidas nómades y caóticas, las personas sin hogar sufren desproporcionadamente de afecciones mentales, adicciones y enfermedades crónicas, y a menudo no tienen seguro médico o si lo tienen no lo usan.

Eso hace que diseñar un negocio alrededor de atenderlos sea un riesgo, dicen ejecutivos de seguros y economistas de la salud.

“Es realmente innovador y emprendedor tomar toda esta energía y coraje para tratar de mejorar las cosas para una población a la que generalmente se ignora”, dijo Mark Duggan, profesor de economía en la Universidad de Stanford que se especializa en política de falta de vivienda y Medicaid. “Los incentivos financieros importan muchísimo en la atención médica. Son todo”.

Se estima que 181,000 personas no tenían hogar en California en 2023, aproximadamente el 30% del total nacional. El número de personas viviendo en la calle, más de dos tercios del total del estado, aumentó 6.9% con respecto al año anterior.

A los líderes estatales, incluido el gobernador demócrata Gavin Newsom, les ha costado luchar contra la creciente crisis de salud pública y política, a pesar de reunir recursos sin precedentes de los contribuyentes.

“Tenemos un gran problema entre manos, y tenemos muchos planes de salud y municipios diciendo, ‘Te necesitamos'”, dijo Jain.

En las calles

Una mañana nublada de abril, en Long Beach, Daniel Speller manejaba su furgoneta médica móvil entre las tiendas de campaña y lonas que llenaban las calles residenciales, buscando a un par de pacientes sin hogar. Speller, que es asistente médico de Healthcare in Action, dijo que estaba particularmente preocupado por las heridas gravemente infectadas que habían desarrollado en sus extremidades después de usar la droga callejera xilazina, un tranquilizante para animales que a menudo se mezcla con fentanilo.

“Estas heridas están en todas partes. Es realmente malo”, dijo Speller. Si las infecciones avanzan, pueden requerir amputaciones de dedos, pies o brazos.

“Hombre, ésta todavía está muy profunda”, dijo Speller mientras despegaba los jeans de la pierna hinchada de Robert Smith, de 66 años.

Después de limpiar y vendar la pierna de Smith, Speller le preguntó si necesitaba algo más. “Perdí mis cupones de alimentos”, respondió Smith.

En menos de una hora, el equipo de trabajadores sociales y enfermeros de Speller habían llamado a un Uber para llevar a Smith a una oficina estatal, donde recibió una nueva tarjeta CalFresh.

Después, Speller dobló hacia una calle lateral llena de más tiendas de campaña y autos convertidos en refugios. Nick Destry Anderson, de 46 años, estaba durmiendo en la acera y necesitaba con urgencia que le curaran su herida.

“Tenía tanto miedo. Antes de conocerlos pensé que iba a perder mi pierna”, dijo Anderson, haciendo un gesto mientras Speller rociaba su pierna con un aerosol antibiótico. “Estas personas salvaron mi vida”.

Anderson dijo que se sentía mareado, así que Speller pidió a otro miembro del equipo que usara la tarjeta de crédito de la empresa para comprarle una hamburguesa con queso y una Sprite.

Muchas personas sin hogar languidecen en las calles, tan arraigadas en crisis de salud mental o adicciones que no les importa mucho ver a un médico o tomar su medicación. Las enfermedades crónicas empeoran. Las heridas se infectan. Las personas sufren sobredosis o mueren por afecciones tratables.

Parte de la medicina callejera consiste en vendar heridas infectadas, administrar inyecciones de antipsicóticos y tratar enfermedades crónicas. Los proveedores de la calle a menudo reparten parafernalia de drogas como agujas limpias y pipas de vidrio para prevenir que se compartan y prevenir infecciones. Quizás más importante, estos trabajadores construyen confianza.

Que los pacientes sin hogar s conecten con médicos y enfermeros de atención primaria, que los visitan en las calles, en los parques o dondequiera que estén, puede prevenir visitas frecuentes y costosas a salas de emergencia y hospitalizaciones, potencialmente ahorrando dinero a las aseguradoras y a los contribuyentes, argumenta Jain.

Aunque los refugios y la vivienda son escasos, el objetivo de Healthcare in Action es lograr que los pacientes estén lo suficientemente saludables como para vivir vidas estables e independientes, dijo.

Pero eso es más fácil decirlo que hacerlo. En West Hollywood esa semana de abril, Isabelle Peng, coordinadora clínica de Healthcare in Action, encontró a Lisa Vernon, una mujer sin hogar, desplomada en su silla de ruedas en una parada de autobús concurrida. Vernon es una habitual del cercano Centro Médico Cedars-Sinai, dijeron Peng y su colega, David Wong.

Cuando Peng y Wong intentaron examinar su pierna hinchada, Vernon les gritó y rechazó la ayuda. “¡Los antibióticos no van a salvar mi vida!”, gritó Vernon mientras un ratón corría hacia las migajas de patatas fritas que estaban a sus pies.

Pasaron a su siguiente paciente, un hombre que estaban rastreando con un dispositivo GPS que a veces colocan en las pertenencias de las personas sin hogar. El uso de los dispositivos es voluntario. Funcionan mejor que los teléfonos móviles porque es menos probable que la policía los confisque durante redadas de campamentos, o que se los roben.

“Nuestros pacientes realmente cambian mucho de ubicación, así que esto nos ayuda a encontrarlos cuando tenemos que darles medicación o hacer seguimiento”, dijo Wong. “Ya hemos desarrollado un vínculo con estos pacientes y ellos quieren que los veamos”.

Aumento de ingresos

Los equipos de medicina de calle están en demanda, en gran parte debido a la creciente frustración pública con la falta de vivienda. Por ejemplo, La ciudad de West Hollywood otorgó a Healthcare in Action un contrato de tres años que paga $47,000 al mes. La organización sin fines de lucro también puede facturar por sus servicios a Medi-Cal, el programa de Medicaid de California.

Mari Cantwell, consultora de atención médica que se desempeñó como directora del Medicaid de California desde 2015 hasta principios de 2020, dijo que los reembolsos de Medicaid por sí solos no son suficientes para financiar a los proveedores de medicina de calle. Para seguir siendo viables, dijo, deben dar pasos financieros creativos, como hace Healthcare in Action.

“Medicaid nunca va a pagar altos márgenes, así que tienes que pensar en cómo sostener las cosas”, dijo.

Healthcare in Action generó unos $2 millones en ingresos en su primer año, $6 millones en 2022 y $15,4 millones en 2023, según Michael Plumb, director financiero de SCAN Group.

Healthcare in Action y el plan de seguro Medicare Advantage de SCAN generan ingresos sirviendo a pacientes sin hogar de múltiples maneras:

• Ambos están aprovechando miles de millones de dólares en fondos de Medicaid que los estados y el gobierno federal están gastando para tratar a personas sin hogar en sus lugares y para proporcionar nuevos servicios sociales como asistencia de vivienda y alimentos. Por ejemplo, Healthcare in Action ha recibido $3,8 millones de la iniciativa de Medicaid de Newsom de $12 mil millones llamada CalAIM, que le permite contratar trabajadores sociales, médicos y proveedores para los equipos de medicina callejera, según el estado. También contrata con aseguradoras de salud, incluidas L.A. Care y Molina Healthcare en el sur de California, para identificar viviendas para pacientes sin hogar, negociar con propietarios, y proporcionar ayuda financiera como cubrir depósitos de seguridad.
• Healthcare in Action recibe donaciones caritativas de algunos hospitales y aseguradoras, incluidas CalOptima en el condado de Orange y su propio plan Medicare Advantage, SCAN Health Plan.
• Healthcare in Action se asocia con ciudades y hospitales para proporcionar tratamiento y servicios. En 2022, inició un contrato con Cedars-Sinai para atender a pacientes que deambulan fuera del hospital.
• También inscribe a pacientes sin hogar elegibles en SCAN Health Plan porque muchas personas mayores de bajos ingresos califican tanto para la cobertura de Medicaid como para Medicare. El plan tuvo ingresos de $4,9 mil millones en 2023, frente a los $3,5 mil millones de 2021.

“Ha habido un ajuste de mercado increíble, desafortunadamente”, dijo Jain. “No puedes caminar o conducir por una calle en Los Ángeles, ya sea rica o pobre, y no encontrarte con este problema”.

Jim Withers, quien acuñó el término “medicina de calle” hace décadas y atiende a personas sin hogar en Pittsburgh, dio la bienvenida a la entrada de más proveedores dada la enorme necesidad. Pero advirtió sobre un modelo con motivos financieros.

“Me preocupa la corporativización de la medicina de calle y el capitalismo invadiendo lo que hemos estado construyendo, en gran parte como una misión de justicia social fuera del sistema tradicional de atención médica”, dijo. “Pero nadie posee las calles, y tenemos que encontrar la manera de trabajar juntos”.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

USE OUR CONTENT

This story can be republished for free (details).

These doctors, nurses, and social workers are fanning out on the streets of Los Angeles to provide health care and social services to homeless people — foot soldiers of a new business model taking root in communities around California.

Their strategy: Build trust with homeless people to deliver medicine wherever they are — and make money doing it.

“The biggest population of homeless people in this country is here in Southern California,” said Sachin Jain, a former Obama administration health official who is CEO of SCAN Group, which runs a Medicare Advantage insurance plan covering about 300,000 people in California, Arizona, Nevada, Texas, and New Mexico.

“The fastest-growing segment of people experiencing homelessness is actually older adults,” he said. “I said, ‘We’ve got to do something about this.’”

Jain’s organization three years ago created Healthcare in Action, a medical group that sends practitioners onto California’s streets solely to care for homeless people. It has grown rapidly, building operations in 17 communities, including Long Beach, West Hollywood, and San Bernardino County.

Since its launch, Healthcare in Action has cared for about 6,700 homeless patients and managed roughly 77,000 diagnoses, from schizophrenia to diabetes. It has placed about 300 people into permanent or temporary housing.

Street medicine in most of the country is practiced as a charitable endeavor, aimed at serving a challenging patient population failed by traditional medicine, its proponents say. Living transient, chaotic lives, homeless people suffer disproportionately from mental illness, addiction, and chronic disease and often don’t have health insurance — or don’t use it if they do.

That makes designing a business around caring for them a risk, insurance executives and health economists say.

“It’s really innovative and entrepreneurial to take all this energy and grit to try and improve things for a population that is too often ignored,” said Mark Duggan, a professor of economics at Stanford University who specializes in homelessness and Medicaid policy. “Financial incentives matter massively in health care. It’s everything.”

An estimated 181,000 people were homeless in California in 2023 — about 30% of the nation’s total. The number living outside, more than two-thirds of California’s total, increased 6.9% over the previous year.

The state’s leaders, including Democratic Gov. Gavin Newsom, have struggled to make inroads against the mounting public health and political crisis — despite marshaling unprecedented taxpayer resources.

“We have a huge problem on our hands, and we have a lot of health plans and municipalities saying, ‘We need you,’” Jain said.

On the Streets

On a cloudy April morning in Long Beach, Daniel Speller navigated his mobile medical van among the tents and tarps that crowded residential streets, searching for a couple of homeless patients. A physician assistant for Healthcare in Action, Speller said he was particularly worried about the badly infected wounds they developed on their limbs after they used the street drug xylazine, an animal tranquilizer often mixed with fentanyl.

“These wounds are everywhere. It’s really bad,” Speller said. If infections progress, they can require toe, foot, or arm amputations.

“Man, this one is still so deep,” Speller said as he peeled denim pants from the swollen leg of Robert Smith, 66.

After cleaning and wrapping Smith’s leg, Speller asked him if he needed anything else. “I lost my food stamps,” Smith replied.

Within the hour, Speller’s team of social workers and nurses had summoned an Uber to take Smith to a state office, where he received a new CalFresh card.

Speller then turned his medical van onto a side street lined with more tents and cars-turned-shelters. Nick Destry Anderson, 46, was sleeping on the sidewalk and badly in need of wound care.

“I was so scared. I thought I was going to lose my leg before I met them,” Anderson said, grimacing as Speller sprayed his leg with antibiotic mist. “These people saved my life.”

Anderson reported feeling lightheaded, so Speller asked another team member to use the company credit card to get him a cheeseburger and a Sprite.

Many homeless people languish on the streets, so entrenched in mental health crises or addiction that they don’t much care about seeing a doctor or taking their medication. Chronic diseases worsen. Wounds grow infected. People overdose or die from treatable conditions.

Part of street medicine is bandaging infected sores, administering antipsychotic injections, and treating chronic diseases. Street providers often hand out drug paraphernalia such as clean needles and glass pipes to reduce sharing and prevent infections. Perhaps more importantly, these workers build trust.

Getting homeless patients established with primary care doctors and nurses — who visit them on the streets, in parks, or wherever they happen to be — can prevent frequent and expensive emergency room trips and hospitalizations, potentially saving money for insurers and taxpayers, Jain argues. Even though shelter and housing are scarce, Healthcare in Action’s goal is to get patients healthy enough to live stable, independent lives, he said.

But that’s easier said than done. In West Hollywood that week in April, Healthcare in Action clinical coordinator Isabelle Peng found Lisa Vernon, a homeless woman, slumped over in her wheelchair at a busy bus stop. Vernon is a regular at nearby Cedars-Sinai Medical Center, Peng and her colleague David Wong said.

When Peng and Wong attempted to examine her swollen leg, Vernon shouted at them and declined aid. “Antibiotics aren’t going to save my life!” Vernon yelled as a mouse scurried for the potato chip shrapnel at her feet.

They moved on to their next patient, a man they were tracking with a GPS device they sometimes affix to homeless people’s belongings. Use of the devices is voluntary. They work better than cellphones because they less often get taken by law enforcement during encampment sweeps or stolen by thieves.

“Our patients really move around a lot, so this helps us go find them when we have to get them medication or do follow-up care,” Wong said. “We have already developed rapport with these patients, and they want us to see them.”

Growing Revenue

Street medicine teams are in demand, largely because of growing public frustration with homelessness. The city of West Hollywood, for instance, awarded Healthcare in Action a three-year contract that pays $47,000 a month. The nonprofit can also bill Medi-Cal, California’s Medicaid program, which covers low-income people, for its services.

Mari Cantwell, a health care consultant who served as California’s Medicaid director from 2015 until early 2020, said Medicaid reimbursements alone aren’t enough to fund street medicine providers. To remain viable, she said, they need to take creative financial steps, like Healthcare in Action has.

“Medicaid is never going to pay high margins, so you have to think about how to sustain things,” she said.

Healthcare in Action brought in about $2 million in revenue in its first year, $6 million in 2022, and $15.4 million in 2023, according to Michael Plumb, SCAN Group’s chief financial officer.

Healthcare in Action and SCAN’s Medicare Advantage insurance plan generate revenue by serving homeless patients in multiple ways:

• Both are tapping into billions of dollars in Medicaid money that states and the federal government are spending to treat homeless people in the field and to provide new social services like housing and food assistance.For instance, Healthcare in Action has received $3.8 million from Newsom’s $12 billion Medicaid initiative called CalAIM, which allows it to hire social workers, doctors, and providers for street medicine teams, according to the state.It also contracts with health insurers, including L.A. Care and Molina Healthcare in Southern California, to identify housing for homeless patients, negotiate with landlords, and provide financial help such as covering security deposits.
• Healthcare in Action collects charitable donations from some hospitals and insurers, including CalOptima in Orange County and its own Medicare Advantage plan, SCAN Health Plan.
• Healthcare in Action partners with cities and hospitals to provide treatment and services. In 2022, it kicked off a contract with Cedars-Sinai to care for patients milling outside the hospital.
• It also enrolls eligible homeless patients into SCAN Health Plan because many low-income, older people qualify for both Medicaid and Medicare coverage. The plan had revenue of $4.9 billion in 2023, up from $3.5 billion in 2021.

“There’s been an incredible market fit, unfortunately,” Jain said. “You can’t walk or drive down a street in Los Angeles, rich or poor, and not run into this problem.”

Jim Withers, who coined the term “street medicine” decades ago and cares for homeless people in Pittsburgh, welcomed the entry of more providers given the enormous need. But he cautioned against a model with financial motives.

“I do worry about the corporatization of street medicine and capitalism invading what we’ve been building, largely as a social justice mission outside of the traditional health care system,” he said. “But nobody owns the streets, and we have to figure out how to play nice together.”

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

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

USE OUR CONTENT

This story can be republished for free (details).

In a 6-to-3 ruling in City of Grants Pass v. Johnson, the justices in the majority said allowing the targeting of homeless people occupying public spaces by enforcing bans on public sleeping or camping with criminal or civil penalties is not cruel and unusual punishment, even if there are no alternative shelter or housing options available for them.

“It’s hard to imagine the chaos that is going to ensue. It’ll have horrible consequences for mental and physical health,” said Ed Johnson, director of litigation at the Oregon Law Center and lead attorney representing homeless defendants in the case.

“If people aren’t allowed to engage in survival while living outside by having things like a blanket and a pillow, or a tarp and a sleeping bag, and they don’t have anywhere else to go, they can die,” he said.

The case, the most consequential on homelessness in decades, comes amid widespread public frustration over the proliferation of homeless encampments — especially in Western cities such as Los Angeles, San Francisco, Phoenix, and Portland, Oregon — and the unsafe and unsanitary conditions that often fester around them.

An estimated 653,100 people were homeless in the United States in 2023, according to the most recent federal estimates, the vast majority residing in shanties, broken-down recreational vehicles, and sprawling tent camps scattered across urban and rural communities.

The Oregon city of Grants Pass, at the center of the legal battle, successfully argued that it was not cruel and unusual punishment to fine and arrest homeless people living outdoors or illegally camping on public property.

Mike Zacchino, a spokesperson for Grants Pass, issued a statement Friday that the city was “grateful” to receive the decision and is committed to assisting residents struggling to find stable housing. Theane Evangelis, the city’s lead attorney, told the Supreme Court in April that if it couldn’t enforce its anticamping laws, “the city’s hands will be tied. It will be forced to surrender its public spaces.”

In the majority opinion, Justice Neil Gorsuch argued that the homelessness crisis is complex and has many causes, writing, “With encampments dotting neighborhood sidewalks, adults and children in these communities are sometimes forced to navigate around used needles, human waste, and other hazards to make their way to school, the grocery store, or work.”

However, Gorsuch wrote, the Eighth Amendment does not give the Supreme Court justices primary responsibility “for assessing those causes and devising those responses.” A handful of federal judges cannot “begin to ‘match’ the collective wisdom the American people possess in deciding ‘how best to handle’ a pressing social question like homelessness,” he wrote.

In a dissenting opinion, Justice Sonia Sotomayor wrote that the decision focuses on the needs of local government and “leaves the most vulnerable in our society with an impossible choice: Either stay awake or be arrested.”

Elected officials, both Republican and Democrat, have increasingly argued that life on the streets is making people sick — and they should be allowed to relocate people for health and safety.

“If government offers people help and they can’t or won’t accept it, there should be consequences. We have laws that need to be used,” said Sacramento Mayor Darrell Steinberg, who is an adviser to California Gov. Gavin Newsom on homelessness, referencing laws that allow the state to require mental health and addiction treatment, for instance.

The high court decision could further embolden cities to sweep encampments and could force homeless people to be more transient — constantly moving around to evade law enforcement. Sometimes they’re offered shelter, but often there is nowhere to go. Steinberg believes many cities will more aggressively sweep encampments and keep homeless people on the move, but he does not believe they should be fined or arrested.

“I’m comfortable telling people that you can’t camp in public, but I would not criminalize it,” he said. “Some cities will fine and arrest people.”

Advocates for homeless people say constant relocations will further imperil the health of this population and magnify public health threats, such as the spread of communicable diseases. They fear conservative-leaning communities will criminalize street camping, pushing homeless people to liberal municipalities that provide housing assistance and services.

“Some cities have decided that they want to fine, arrest, and punish people for being homeless, and the majority opinion tells communities that they can go ahead and do that,” said Steve Berg, chief policy officer for the National Alliance to End Homelessness. “If communities really want less homelessness, they need to do what works, which is make sure people have access to housing and supportive services.”

As they disperse and relocate — and possibly get arrested or slapped with fines — they will lose connections to the doctors and nurses who provide primary and specialty care on the streets, some health care experts say.

“It just is going to contribute to more death and higher mortality rates,” said Jim O’Connell, the president of Boston’s Health Care for the Homeless Program and an assistant professor of medicine at Harvard Medical School. “It’s tough, because there’s a public safety versus public health” debate cities are struggling with.

As homeless people become sicker, they will get more expensive to treat, O’Connell said.

“Stop thinking about the emergency room, which is cheap compared to what we actually see, which is homeless people being admitted to the ICU,” he said. “I’ve got 20-something patients at Mass General today taking a huge amount of money to care for.”

In Los Angeles, which has one of the biggest homeless populations in America, street medicine provider Brett Feldman predicts more patients will need emergency intensive care as chronic conditions like diabetes and heart disease go untreated.

Patients on anti-addiction medication or those undergoing treatment to improve their mental health will also struggle, he said.

“People are already getting moved and camps swept all the time, so we already know what happens,” Feldman said. “People lose their medications; they lose track of us.”

Homeless people die at rates two to six times higher than residents living in stable housing, according to a May report from the Los Angeles County Department of Public Health. Drug overdoses and coronary artery disease were the top two causes of death since 2017.

Feldman said it may become harder to house people or place them into treatment programs.

“We rely on knowing where they are in order to find them,” Feldman said. “And they rely on us knowing where they are to get their health care. And if we can’t find them, often they can’t complete their housing paperwork and they don’t get inside.”

The Biden administration has pushed states to expand the definition of health care to include housing. At least 19 are directing money from Medicaid — the state-federal health insurance program for low-income people — into housing aid.

California is going the biggest, pumping $12 billion into an ambitious Medicaid initiative largely to help homeless patients find housing, pay for it, and avoid eviction. It is also dramatically expanding street medicine services.

The Supreme Court decision could interrupt these programs, said Margot Kushel, a primary care doctor and homelessness researcher at the University of California-San Francisco.

“Now you’re going to see disconnections from those case managers and housing navigators and people just losing touch in the chaos and the shuffle,” she said. “What’s worse, though, is we are going to lose the trust that is so essential to getting people to take their medications or stop their drug use and, ultimately, getting people into housing.”

Kushel said the ruling would make homelessness worse. “Just having fines and jail time makes it easier for a landlord to reject you for housing,” she said.

At the same time, Americans are increasingly frustrated by encampments spreading into neighborhoods, ringing public parks, and popping up near schools. The spread is marked by more trash, dirty needles, rats, and human excrement on sidewalks.

Local leaders across deep-blue California welcomed the decision from the conservative majority, which will allow them to fine and arrest homeless people, even if there’s nowhere for them to go. “The Supreme Court today took decisive action that will ultimately make our communities safer,” said Graham Knaus, CEO of the California State Association of Counties.

Newsom, a Democrat who leads a state with nearly 30% of the nation’s homeless population, said the decision gives state and local officials “the definitive authority to implement and enforce policies to clear unsafe encampments from our streets,” ending legal ambiguity that has “tied the hands of local officials for years and limited their ability to deliver on common-sense measures to protect the safety and well-being of communities.”

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

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

USE OUR CONTENT

This story can be republished for free (details).

BIRNAMWOOD, Wis. — The land of fried cheese curds and the Green Bay Packers is among a half-dozen battleground states that could determine the outcome of the expected November rematch between President Joe Biden and former President Donald Trump — a contest in which the cost and availability of health care are emerging as defining issues.

At church picnics and summertime polka festivals that draw voters of all political stripes, Wisconsinites said they’re struggling to pay for even the most basic health care, from common blood tests to insulin prescriptions. A proposal by Wisconsin’s Democratic governor to expand the state’s Medicaid program to thousands of low-income residents has become a partisan lightning rod in the affordability debate: Democrats want it; Republicans don’t.

In 2020, voters here gave Biden, a Democrat, a narrow win after favoring Trump, a Republican, in 2016. Recent polling indicates that the two rivals were neck and neck in this year’s race. They were scheduled to square off tonight in the first televised debate of the campaign.

Many Wisconsin voters still can’t figure out whom to vote for — or whether to vote at all.

“I know he’s trying to improve health care and inflation, but I’m not happy with Biden,” said Bob Prelipp, 79, a Republican who lives in Birnamwood, a village of about 700 people in rural central Wisconsin. He reluctantly voted for Biden in 2020, after voting for Trump in 2016.

Prelipp was serving beer at the Birnamwood Polka Days festival on a muggy June day. Pro-Trump hats peppered the crowd, and against the backdrop of cheerful polka tunes, peppy dancing, and the sweet smell of freshly cut hay, candidates for local and state office mingled with voters.

This rural part of the state is ruby red. Trump flags fly over the landscape and businesses proudly display pro-Trump paraphernalia. Biden supporters are more visible and vocal in the Wisconsin population centers of Madison, the capital, and Milwaukee.

Biden “needs to get prices down. Everything is getting so unaffordable, even health care,” said Prelipp, a Vietnam War veteran who said his federal health care for veterans has improved markedly under Biden, including wait times for appointments. Yet he said he can’t stomach the idea of voting for him again, or for Trump, who has disparaged military veterans.

Prelipp said people are feeling nickel-and-dimed, not only at the grocery store and gas pump, but also at doctors’ offices and hospitals.

Greg Laabs, a musician in one of the polka bands at Birnamwood, displayed a pro-Trump sticker on his tuba. He said he likes his federal Medicare health coverage but worries that if Biden is reelected Democrats will provide publicly subsidized health care to immigrants lacking legal residency.

“There are thousands of people coming across the border,” said Laabs, 71. He noted that both Biden and Vice President Kamala Harris endorsed providing public health care to immigrants without legal residency as presidential candidates in 2019, a position that Harris’ home state of California has enthusiastically embraced. “We cannot support the whole world,” Laabs said.

The two main political parties will pick presidential nominees at their national conventions, and Biden and Trump are widely expected to be their choices. Republicans will gather in Milwaukee in July. Democrats will convene in Chicago in August.

Biden is trying to make health care a key issue ahead of the Nov. 5 election, arguing that he has slashed the cost of some prescription medications, lowered health insurance premiums, and helped get more Americans covered under the Affordable Care Act, also known as Obamacare. He has also been a strong supporter of reproductive rights and access to abortion, particularly since the U.S. Supreme Court struck down Roe v. Wade two years ago.

“The choice is clear: President Biden will protect our health care,” claims one of Biden’s campaign commercials.

Trump has said he wants to repeal Obamacare, despite multiple failed Republican attempts to do so over several years. “The cost of Obamacare is out of control,” Trump wrote last year. “I’m seriously looking at alternatives.”

Even Democrats who back Biden say the president must make it easier and cheaper to get medical care.

“I signed up for one of the Obamacare plans and got my cholesterol and blood sugar tested and it was like $500,” said Mary Vils, 63, a Democrat who lives in Portage County in central Wisconsin.

She strongly supports Biden but said people are feeling squeezed. “We’re fortunate because we had some savings, but that’s a lot of money out-of-pocket.”

Wisconsin Gov. Tony Evers, a Democrat, said he understands “the frustration that people have.”

Evers has repeatedly attempted to expand Medicaid to low-income adults who don’t have children, which all but 10 states have done since the enactment of Obamacare in 2010. The state’s Republican-controlled legislature has repeatedly blocked his efforts, yet Evers is trying again. Expanding Medicaid would provide coverage to nearly 90,000 low-income people, according to his administration.

Evers, who supports Biden, has argued that expanding Medicaid would bring in $2 billion in federal funding that would help reimburse hospitals and insurers for uncompensated care, and ultimately “make health care more affordable.”

Many states that have expanded Medicaid have realized savings in health care spending while providing coverage to more people, according to the Center on Budget and Policy Priorities, a think tank based in Washington, D.C.

“We have to get the Medicaid expansion money,” Evers told KFF Health News. “That would solve a lot of problems.”

Biden’s campaign is opening field offices in Wisconsin, and he and federal health care officials make frequent visits to the state. They’re touting Biden’s record of increasing subsidies for Obamacare insurance plans, and promising to expand access to care, especially in rural communities.

“Millions more people have coverage today,” said Neera Tanden, a domestic policy adviser to Biden, at a mid-June town hall event in Rothschild, Wisconsin, to announce $11 million in new federal funding to recruit and train health care workers.

She said the gains in Obamacare coverage have helped achieve “the lowest rate of uninsurance at any time in American history. That’s not an accident.”

But attendees at the town hall event told Tanden and the secretary of Health and Human Services, Xavier Becerra, that they have lost access to care as hospitals and rural health clinics have closed.

“We had a hospital that’s been serving our community for over 100 years close very suddenly,” said Michael Golat, an Altoona, Wisconsin, resident who described himself as an independent voter. “It’s really a crisis here.”

Becerra encouraged Wisconsin lawmakers to expand Medicaid. “Instantaneously, you would have hundreds of thousands of Americans in rural America, and including in rural Wisconsin, who now have access to care,” he said.

Cory Sillars, a Republican running for the Wisconsin State Assembly who campaigned at the Birnamwood polka festival, opposes Medicaid expansion and said the state should instead grant nurses the authority to practice medicine without doctor supervision, which he argued would help address gaps in rural care.

“If you’re always expanding government programs, you get people hooked on government and they don’t want to do it themselves. They expect it,” he said.

Sillars is running as a “pro-life” candidate with “traditional, Christian values,” an anti-abortion stance that some Democrats hope will backfire up and down the ballot.

Kristin Lyerly, an obstetrician-gynecologist and a Democrat, has made access to abortion and contraception central to her campaign to fill the congressional seat vacated by Mike Gallagher, a Republican who resigned in April.

Lyerly lives outside Green Bay but practices in Minnesota after facing threats and harassment, largely from conservative extremists, she said. She was a plaintiff in the state’s legal bid to block Republicans from halting access to abortions. Abortions still are not available everywhere in Wisconsin, she said.

“It is incumbent upon me as a physician and a woman to stand up and to use my voice,” Lyerly said. “This is an issue that people in this district might not be shouting about, but they’re having conversations about it, and they’re going to vote on it.”

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

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

USE OUR CONTENT

This story can be republished for free (details).

Biden narrowly won Wisconsin in 2020, after it went for Trump in 2016. And while recent polling indicates that Trump now holds a slight edge, many people here still can’t figure out whom to vote for, or whether to vote at all. Across the state, the rising cost of health care is high on their list of concerns.

A Wisconsinite to my core, I wanted to gauge what is motivating voters. Among the best places to understand the state’s mood are the many summertime polka festivals that draw voters of all political stripes.

This past weekend, for instance, I met Bob Prelipp, 79, at the Birnamwood Polka Days in Birnamwood, population about 700.

A Republican who served in Vietnam during his stint in the Navy, Prelipp voted for Trump in 2016, then switched to Biden in 2020. Prelipp said Trump angered him with his comments disparaging military veterans.

After Trump supporters stormed the U.S. Capitol on Jan. 6, 2021, “I knew I couldn’t vote for him again,” Prelipp said. “I can’t believe we can’t find a better Republican candidate. I’m still trying to decide what to do.”

His veteran health care has improved remarkably under Biden, yet he still can’t stomach voting for him. “I’m not happy with Biden,” he said. “Everything is getting so unaffordable, even health care.”

Birnamwood is in a rural part of the state that’s ruby red — Trump hats pepper the crowd and Trump flags dot the landscape. Biden supporters are more visible in liberal, heavily populated cities like Madison and Milwaukee.

Greg Laabs, a tuba player in a local polka band, proudly displays a Trump sticker on his instrument.

“There are thousands of people coming across the border,” Laabs said, expressing concern over a Democratic president providing immigrants lacking legal residency access to health care — an idea he recalled Vice President Harris supporting in 2019 and that California has passed. “We cannot support the whole world.”

Meanwhile, Biden and members of his administration are trying to win over voters by touting major Obamacare expansions while promising to do more to expand access to care, especially in rural communities.

“Nine million more people have health care because of fights this administration has taken,” Neera Tanden, Biden’s domestic policy adviser, said last week in the city of Rothschild, announcing an $11 million federal investment in the health-care workforce. “There’s a clear choice.”

But Wisconsin voters at the Rothschild town hall-style event told Tanden and Health and Human Services Secretary Xavier Becerra that the state losing hospitals and clinics has upended access.

“We had a hospital that’s been serving our community for over 100 years close very suddenly,” said Michael Golat, an independent voter who lives in the town of Altoona and believes Biden would prioritize health care, yet says the president must do more to expand access to health care and mental health treatment. “It’s really a crisis here.”

This article is not available for syndication due to republishing restrictions. If you have questions about the availability of this or other content for republication, please contact NewsWeb@kff.org.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

USE OUR CONTENT

This story can be republished for free (details).

The Golden State was the first to win approval from the Biden administration to cover the sobriety payments, with Medicaid wrapping it into an ambitious health-care initiative spearheaded by Democratic Gov. Gavin Newsom to provide the state’s sickest residents with a broad array of behavioral health and social services. Washington state and Montana have since followed.

California is focusing on stimulants, including cocaine and meth. 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.

Addiction doctors say the treatment, called “contingency management,” can be lifesaving. Lethal overdoses in California from meth, including other psychostimulants, have spiked 129 percent since 2019 and from cocaine 102 percent, according to a KFF Health Newsanalysis of estimates from the Centers for Disease Control and Prevention.

“Contingency management is the gold standard for stimulant use disorder because you can win things for good behavior. But not a lot of places are providing it yet,” said PK Fonsworth, a psychiatric emergency room doctor and addiction psychiatrist in Los Angeles. “A lot of patients I see on amphetamines show up with these extreme highs and lows, manic behavior, and it can turn into a meth-induced psychosis or kill you.”

An intense policy focus on opioids helped reduce overdose deaths slightly from 2022 to 2023, even as use skyrocketed during the coronavirus pandemic. In the meantime, though, two older scourges — methamphetamine and cocaine — emerged as major public health threats.

The number of Americans who died from overdosing on meth jumped a staggering 117 percent from pre-pandemic levels, and cocaine overdose deaths rose about 83 percent, data shows.

The CDC data, released this month, shows that about 36,000 Americans died from methamphetamine in 2023, up from about 17,000 in 2019. Cocaine killed nearly 30,000 people in 2023, up from 16,000 in 2019.

Research shows promise for contingency management. For instance, study participants achieve significant periods of sobriety, agree to long-term addiction treatment and even reduce risky sexual behavior.

The Biden administration is pushing more states to consider the approach, calling it a “proven treatment” that “remains underutilized.”

So far, 19 of California’s 58 counties have enrolled a total of about 2,700 stimulant users.

The biggest take-up is in Los Angeles County, the most populous county in the United States, where public health officials cited contingency management as one of the only effective ways to curb stimulant use.

There are no consequences for failing a drug test. Participants simply don’t get paid that day but can try again later.

Quinn Coburn, a self-described longtime addict, has remained sober on the program in the rural Northern California town of Grass Valley, amassing more than $500 so far.

“It’s that little something that’s holding me accountable,” said Coburn, a former construction worker who said he has tried repeatedly to kick his habit.

This article is not available for syndication due to republishing restrictions. If you have questions about the availability of this or other content for republication, please contact NewsWeb@kff.org.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

USE OUR CONTENT

This story can be republished for free (details).

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.

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 health 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.

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.

“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.

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.”

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.

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.

“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. 

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

USE OUR CONTENT

This story can be republished for free (details).