The Golden State was the first to from the Biden administration to cover the sobriety payments, with Medicaid wrapping it into an spearheaded by Democratic Gov. Gavin Newsom to provide the state’s sickest residents with a broad array of behavioral health and social services. state and 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 “,” can be lifesaving. Lethal overdoses in California from meth, including other , have spiked 129 percent since 2019 and from cocaine 102 percent, according to a Ģ��ӰԺ Health Newsanalysis of 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 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 slightly from 2022 to 2023, even as use skyrocketed during the 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.

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, 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 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.

, 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.

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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 . 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 “,” 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 , 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 . 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 into curbing opioid addiction and , 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 .

Although the cutting-edge treatment 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 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, .

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 “,” a California Healthline series exploring the impact of the state’s safety-net health program on enrollees.

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The is common in places like Southeast Asia, East Africa, and Latin America, and when Americans contract the disease it is usually while traveling. But , the patient hadn’t left California.

Epidemiologists and public health nurses visited 175 households to conduct blood draws and local pest control workers began fumigating the patient’s neighborhood. In the process, they discovered a second infected person who hadn’t traveled.

Both patients recovered, and in that neighborhood nearly 65% of the carrier mosquitoes, part of a , were eradicated within seven days, said Matthew Feaster, an epidemiologist with the Pasadena Public Health Department.

The swift and intensive response was funded largely by a new bucket of money in the state budget for public health and preparedness across California, said Manuel Carmona, Pasadena’s deputy director of public health.

In the midst of the covid-19 pandemic, and facing pleas from public health officials who said they didn’t have enough resources to track and contain the disease, California Gov. Gavin Newsom had agreed to allocate $300 million each year for the state’s chronically underfunded public health system.

Two years after the money started to flow, and facing a , the second-term Democratic governor proposes to slash the funding entirely.

“This is a huge step backwards,” said Kat DeBurgh, executive director of the Health Officers Association of California. “We can’t go back to where we were before the pandemic. That future looks very scary.”

Michelle Gibbons, executive director of the County Health Executives Association of California, said about 900 public health workers have already been hired with the new funding — including some of Pasadena’s disease investigators — positions that are at risk should Newsom prevail.

The governor unveiled his for the 2024-25 fiscal year on May 10, saying it pained him to push such deep cuts to health and human services but that the state needed to make “difficult decisions” to balance its budget. Unlike the federal government, it cannot operate on a deficit.

Tense budget negotiations are underway between Newsom and the leaders of the state Senate and Assembly, who must reach an agreement on the state’s estimated $288 billion budget by .

“We have a shortfall. We have to be sober about the reality, what our priorities are,” Newsom said after unveiling his suggested cuts. “This is a program that we wish we could continue to absorb and afford.”

Public health officials lobbied Newsom hard in 2020 and 2021 to get more resources, and secured additional annual funding of $100 million for the state Department of Public Health and $200 million for the 61 local health departments that form the backbone of California’s public health system.

Now they are — just as cities and counties had begun using it to bolster California’s public health defenses.

Some of the workers hired with the money are battling homelessness, fighting climate change, or surveying farmworkers to identify their health and social needs, but most are communicable disease specialists such as epidemiologists and public health nurses charged with investigating threats and outbreaks.

Measles infections are breaking out , , , . Long Beach early this month over an outbreak of tuberculosis, which spreads through the air when an infected person coughs, speaks, or sneezes. Los Angeles public health authorities a spate of hepatitis A infections among homeless people.

And around the United States, the from animals to humans is causing widespread concern.

“The more time this virus is out there transferring between cows and birds, the more chance it has to evolve and spread human to human,” DeBurgh said. She argues that public health agencies must have enough funding to hire workers who can halt threats as they emerge — like they did in Pasadena.

“That dengue outbreak was stopped because we had more ability to hire, and that was a huge public health success,” she said.

Pasadena public health authorities teamed up with the local mosquito control agency to spray pesticides and deployed 29 staffers to test residents for dengue.

“We put our best people on that case,” Carmona said, adding that four of the disease investigators were funded with about $1 million in new state money the department receives each year. “Without it, we wouldn’t have a timely response and we probably would have identified dengue as West Nile or some other type of viral virus.”

Rob Oldham, the interim public health officer and director of Health and Human Services for Placer County, said he’s weighing the “devastating” cuts he’d have to make if Newsom’s proposal passes. The county has hired 11 full-time and six part-time workers using about $1.8 million in new annual state funding, he said.

“This money was just starting to take hold,” he said. “Honestly, we’re scrambling, just as we’re responding to another measles case.”

Legislative leaders were reluctant to say whether they would try to safeguard the funding, as they face deep cuts in nearly every sector of state government, including early childhood education, public safety, energy, and transportation.

“We’re knee-deep in budget negotiations but we’re working like hell to protect the progress we’ve made,” said state Senate leader Mike McGuire, a Northern California Democrat.

Public health officials warned the state would be vulnerable to health and economic disasters should they lose the hard-won funding.

“It’s tempting to go back to what we had before, because when we do our jobs, we are invisible. Crises are averted,” Gibbons said. “But it’s devastating to think of going back to this boom-and-bust cycle of public health funding that goes neglect, panic, repeat.”

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“He’s had these problems since he was born, and I couldn’t figure out what was triggering his asthma,” Fabiola Sandoval said of her son, Jorge, now 4. “It’s so hard when your child is hurting. I was willing to try anything.”

In January, community health workers visited Sandoval’s home in Turlock, a city in California’s Central Valley where dust from fruit and nut orchards billows through the air. They scoured Sandoval’s home for hazards and explained that harsh cleaning products, air fresheners, and airborne dust and pesticides can trigger an asthma attack.

The team also provided Sandoval with air purifiers, a special vacuum cleaner that can suck dust out of the air, hypoallergenic mattress covers, and a humidity sensor — goods that retail for hundreds of dollars. Within a few months, Jorge was breathing easier and was able to run and play outside.

The in-home consultation and supplies were paid for by Medi-Cal, California’s Medicaid health insurance program for low-income residents. Gov. Gavin Newsom is spearheading an ambitious to transform Medi-Cal into both a health insurer and a social services provider, one that relies not only on doctors and nurses, but also community health workers and nonprofit groups that offer dozens of services, including delivering healthy meals and helping homeless people pay for housing.

These groups are redefining health care in California as they compete with businesses for a share of the money, and become a new arm of the sprawling Medi-Cal bureaucracy that serves low-income residents on an annual budget of $158 billion.

But worker shortages, negotiations with health insurance companies, and learning to navigate complex billing and technology systems have hamstrung the community groups’ ability to deliver the new services: Now into the third year of the ambitious five-year experiment, only a small fraction of eligible patients have received benefits.

“This is still so new, and everyone is just overwhelmed at this point, so it’s slow-going,” said Kevin Hamilton, a senior director at the Central California Asthma Collaborative.

The collaborative has served about 3,650 patients, including Sandoval, in eight counties since early 2022, he said. It has years of experience with Medi-Cal patients in the Central Valley and has received about $1.5 million of the new initiative’s money.

By contrast, CalOptima Health, Orange County’s primary Medi-Cal insurer, is new to offering asthma benefits and has signed up 58 patients so far.

“Asthma services are so difficult to get going” because the nonprofit infrastructure for these services is virtually nonexistent, said Kelly Bruno-Nelson, CalOptima’s executive director for Medi-Cal. “We need more community-based organizations on board because they’re the ones who can serve a population that nobody wants to deal with.”

Newsom, a Democrat in his second term, says his signature health care initiative, , seeks to reduce the cost of caring for the state’s sickest and most vulnerable patients, including homeless Californians, foster children, former inmates, and people battling addiction disorders.

In addition to in-home asthma remediation, CalAIM offers of social services, plus a benefit connecting eligible patients with one-on-one care managers to help them obtain anything they need to get healthier, from grocery shopping to finding a job.

The 25 managed-care insurance companies participating in Medi-Cal can choose which services they offer, and contract with community groups to provide them. Insurers have hammered out about 4,300 large and small contracts with nonprofits and businesses.

So far, about 103,000 Medi-Cal patients have received CalAIM services and roughly 160,000 have been assigned personal care managers, , a sliver of the hundreds of thousands of patients who likely qualify.

“We’re all new to health care, and a lot of this is such a foreign concept,” said Helena Lopez, executive director of , a nonprofit organization providing social services in Riverside and San Bernardino counties, such as handing out baseball cleats to children to help them be active.

Tiffany Sickler runs , which offers California foster children mental health and other types of care, and even helped a patient pay off parking tickets. But the program is struggling on a shoestring budget.

“If you want to do this, you have to learn all these new systems. It’s been a huge learning curve, and very time-consuming and frustrating, especially without adequate funding,” she said.

Brandon Richards, a Newsom spokesperson, defended CalAIM, saying that it was “on the cutting edge of health care” and that the state was working to increase “awareness of these new services and support.”

For nonprofits and businesses, CalAIM is a money-making opportunity — one that top state health officials hope to make permanent. Health insurers, which receive hefty payments from the state to serve more people and offer new services, share a portion with service providers.

In some places, community groups are competing with national corporations for the new funding, such as Mom’s Meals, an Iowa-based company that delivers prepared meals across the United States.

Mom’s Meals has an advantage over neighborhood nonprofit groups because it has long served seniors on Medicare and was able to immediately start offering the CalAIM benefit of home-delivered meals for patients with chronic diseases. But even Mom’s Meals isn’t reaching everyone who qualifies, because doctors and patients don’t always know it’s an option, said Catherine Macpherson, the company’s chief nutrition officer.

“Utilization is not as high as it should be yet,” she said. “But we were well positioned, because we already had departments to do billing and contracting with health care.”

Middleman companies also have their eye on the billions of CalAIM dollars and are popping up to assist small organizations to go up against established ones like Mom’s Meals. For instance, the New York-based is advising homeless service providers how to get more contracts and expand benefits.

, with 70 member organizations, is helping smaller nonprofit groups develop and deliver services primarily for families and foster children. Full Circle has signed a deal with Kaiser Permanente, allowing the health care giant to access its network of community groups.

“We’re allowing organizations to launch these benefits much faster than they’ve been able to do and to reach more vulnerable people,” said Camille Schraeder, chief executive of Full Circle. “Many of these are grassroots organizations that have the trust and expertise on the ground, but they’re new to health care.”

One of the biggest challenges community groups face is hiring workers, who are key to finding eligible patients and persuading them to participate.

Kathryn Phillips, a workforce expert at the California Health Care Foundation, said there isn’t enough seed money for community groups to hire workers and pay for new technology platforms. “They bring the trust that is needed, the cultural competency, the diversity of languages,” she said. “But there needs to be more funding and reimbursement to build this workforce.”

Health insurers say they are trying to increase the workforce. For instance, L.A. Care Health Plan, the largest Medi-Cal insurer in California, has given $66 million to community organizations for hiring and other CalAIM needs, said Sameer Amin, the group’s chief medical officer.

“They don’t have the staffing to do all this stuff, so we’re helping with that all while teaching them how to build up their health care infrastructure,” he said. “Everyone wants a win, but this isn’t going to be successful overnight.”

In the Central Valley, Jorge Sanchez is one of the lucky early beneficiaries of CalAIM.

His mother credits the trust she established with community health workers, who spent many hours over multiple visits to teach her how to control her son’s asthma.

“I used to love cleaning with bleach” but learned it can trigger breathing problems, Sandoval said.

Since she implemented the health workers’ recommendations, Sandoval has been able to let Jorge sleep alone at night for the first time in four years.

“Having this program and all the things available is amazing,” said Sandoval, as she pointed to the dirty dust cup in her new vacuum cleaner. “Now my son doesn’t have as many asthma attacks and he can run around and be a normal kid.”

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The administration’s eleventh-hour move, which it attributed to the cost of the new regulations, angered workplace safety advocates and state regulators, setting off a mad scramble to implement emergency rules before summer.

But it’s unclear how, when, or if the emergency rules will come down, and whether they’ll be in place in time to protect workers from the intensifying heat.

“It’s the administration’s moral obligation to fix this,” said Lorena Gonzalez Fletcher, a former state lawmaker and the chief officer of the California Labor Federation, which represents more than 1,300 unions. “There needs to be emergency regulations or legislation quickly, because we can’t stop summer.”

California has had heat standards on the books for outdoor workers , and indoor workplaces were supposed to be next. The proposed standards would have required work sites to be cooled below 87 degrees Fahrenheit when employees are present and below 82 degrees in places where workers wear protective clothing or are exposed to radiant heat, such as furnaces. Buildings could be cooled with air conditioning, fans, misters, and other methods.

The rules would have allowed workarounds for businesses that couldn’t cool their workplaces sufficiently, such as laundries or restaurant kitchens.

Despite concerns from the administration, the California Occupational Safety and Health Standards Board approved the rules at its March 21 meeting, prompting a tense political standoff between workplace safety advocates and Newsom, the second-term Democratic governor who has sought to elevate his national profile and claim progressive leadership on climate change and worker rights — key platforms for the Democratic Party.

State Department of Finance spokesperson H.D. Palmer said the issue isn’t the state’s ballooning budget deficit — estimated between and — but a to nail down the cost of the rules to the state government.

“It wasn’t, ‘We’re trying to sink these regulations,’” Palmer said.

Palmer said the administration received a murky cost estimate from the California Department of Corrections and Rehabilitation indicating that implementing the standards in its prisons and other facilities could cost billions. The , on the other hand, pegged the cost at less than $1 million a year.

“Without our concurrence of the fiscal estimates, those regulations in their latest iteration will not go into effect,” he said.

According to Corrections spokesperson Albert Lundeen, the rules would entail major spending that could require the legislature to fund “extensive capital improvements.” He added that the agency is committed to discussing “how these regulations could be implemented cost-effectively at our institutions to further bolster worker safety.”

Board members argue the state has had years to analyze the cost of the proposed standards, and that it must quickly impose emergency regulations. But it’s not clear how that might happen, whether in days by the administration or months via the state budget process — or another way.

“This is a public health emergency,” said Laura Stock, a board member who is also an at the University of California-Berkeley.

Newsom spokesperson Erin Mellon defended the move to halt permanent regulations, saying approving them would be “imprudent” without a detailed cost estimate.

“The administration is committed to implementing the indoor heat regulations and ensuring workplace protections,” she said in a statement. “We are exploring all options to put these worker protections in place, including working with the legislature.”

Only have adopted heat rules for indoor workers. Legislation has , and even though the Biden administration has initiated the long process of establishing national heat standards for outdoor and indoor work, they may take years to finalize.

in California from indoor heat between 2010 and 2017. Heat stress can lead to heat exhaustion, heatstroke, cardiac arrest, and kidney failure. In 2021, the Centers for Disease Control and Prevention reported, occurred nationally, which is likely an undercount because health care providers are not required to report them. It’s not clear how many of these deaths are related to work, either indoors or outdoors.

The process to adopt California’s indoor head standards started in 2016 and involved years of negotiations with businesses and labor advocates.

Several board members acknowledged that they were frustrated by the administration’s lack of support when they adopted the regulations in March — after their meeting was temporarily halted by angry, chanting warehouse workers — knowing they would not go into effect. Instead, they said, they wanted to amplify pressure on Newsom.

“Every summer is hotter than the last, and workers who aren’t protected are going to suffer heat illness or death,” said Dave Harrison, a board member and with Operating Engineers Local 3. “Our hope was that the vote would be symbolic in sending a message to the state government that, listen, this is important, so we decided to vote on it anyway and put it back into the state’s court.”

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Proposition 1 would fund thousands of new housing units and treatment beds with a $6.4 billion bond and by redirecting $3 to $4 billion in existing mental health tax revenue.

It is the latest in Newsom’s arsenal of policy ideas to attack homelessness and marks the most aggressive push in the nation to get people off the streets, into housing, and connected with health care.

Newsom argues the measure is key to gaining control of the public health crisis, in part by aggressively addressing the drug and alcohol addiction that prevents so many homeless people from getting into stable housing.

Yet Newsom, a two-term Democratic governor with national ambitions, has struggled to convince voters that California can responsibly use the money to address the epidemic.

As of March 11, Proposition 1 in balloting — 50.4% for vs. 49.6% opposed. Tallying the final vote could take weeks, though Newsom advisers said they’re confident the measure will ultimately prevail.

Health and policy experts say the tight race reflects public skepticism over pouring billions more into homelessness interventions that critics argue aren’t making a visible difference.

“There’s been a ton of money going into homelessness with very little progress; the crisis is just getting worse,” said Dan Drummond, executive director of the Sonoma County Taxpayers Association. He said he is a lifelong Democrat and voted for Newsom but has lost confidence that Newsom — and state government — can handle the crisis, so he voted against the measure.

Tents and plywood lean-tos are crowding streets and sidewalks from rural Northern California to San Diego. More than in California, according to the most recent federal tally, and thousands who can’t afford housing are living in unsanitary and unsafe conditions, exposed to extreme cold or scorching heat. Often, they struggle with drug use and untreated mental illness.

Newsom has risked enormous political capital on the issue. During a campaign blitz in early March, Newsom promised 11,150 new housing units and treatment beds and broader mental health reforms, including ongoing money for and addiction treatment.

No other state has tried as hard as California to attack homelessness. Newsom created an initiative to convert hotels and motels into permanent housing for homeless people. He is asking the Biden administration for permission to provide six months of free rent for homeless people. He launched a Medicaid initiative to provide other social services and housing supports for those on the streets or at risk of becoming homeless. The governor has spearheaded new laws to mandate treatment for those with serious mental health conditions.

So far, Newsom has plowed more than $20 billion into the crisis, with billions more for health and social services. Newsom says at least 71,000 people have gotten off the streets, yet the public health crisis is worsening. Homelessness has risen 20% since he took office in 2019, and addiction and mental illness are more rampant, experts say.

“It is very hard to sit here and tell you that I think we’re solving the problem, or that Prop. 1 will solve the problem, even with the billions and billions we are spending,” said Stephen Manley, a Santa Clara County Superior Court judge who cases involving homeless people facing mental health- and drug-related misdemeanors and felonies.

“I’ve got people stuck in jail even though I’ve ordered them released because there’s no beds or housing available, and numbers on the streets just keep rising,” he said.

In California, an estimated 48% of homeless people regularly use hard drugs or drink alcohol heavily, have hallucinations, or have had a recent psychiatric hospitalization, said Margot Kushel, a primary care doctor at Zuckerberg San Francisco General Hospital and Trauma Center and a leading homelessness researcher at the University of California-San Francisco.

The missing piece, Newsom said while campaigning for the initiative in the Coachella Valley, is Proposition 1. He argued the state desperately needs the infusion of money to fund new treatment beds and housing, complemented by social services to help people get healthy and stay housed.

“All of this is considered part of this larger mosaic, but the beds are foundational,” Newsom told Ģ��ӰԺ Health News.

Tom Insel, a neuroscientist and psychiatrist who formerly led the National Institute of Mental Health, also served as Newsom’s “.” Though he supports Proposition 1, he said it would “not be a silver bullet.”

If the measure passes, he said, “the execution and implementation on the ground is going to be critical to achieving success. We’re not great at these capital projects in California. It takes a lot of time that we don’t have.”

Insel and other addiction experts said the initiative could alleviate bottlenecks in the health care system that can lead to overcrowded emergency rooms and delay care. Homeless people experiencing drug or mental health crises regularly flock to hospitals because they have nowhere else to go.

“We need help at every single level. We need psychiatric and detox beds, long-term addiction beds, permanent supportive housing,” said PK Fonsworth, an addiction psychiatrist who treats a steady stream of patients with psychosis and addiction in the emergency room at MLK Community Hospital in South Los Angeles. “Every day in the emergency room, there’s a list of dozens of patients that need psychiatric care, especially those suffering from homelessness and addiction. But what I can offer them is extremely limited.”

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Newsom asked voters on Tuesday to approve his $6.4 billion bond measure, dubbed “Treatment not Tents” — the nation’s most aggressive effort to get people off the streets and connected with health care and housing. The governor calls it key to gaining control of a public health emergency. Because California accepts mail-in ballots until March 12, tallying the final vote .

More than 181,000 people are homeless in California, according to the , and thousands who can’t afford housing are living in unsanitary and unsafe conditions, exposed to extreme cold or scorching heat. Often, they struggle with drug use and untreated mental illness.

During a campaign blitz this month, Newsom promised that Proposition 1 would fund thousands of housing units and treatment beds and broader mental health reforms, including ongoing money for and addiction treatment.

Yet Newsom, a two-term Democratic governor with national ambitions, has struggled to persuade voters that California can responsibly use the money to ease the homelessness epidemic. As of early today, Proposition 1 in balloting — 50.3 percent yes vs. 49.7 percent no.

Newsom advisers expect that narrow lead to hold and the measure to pass, though the considerable opposition reflects public skepticism over pouring billions more into homelessness interventions that critics say aren’t making a visible difference.

“There’s been a ton of money going into homelessness with very little progress; the crisis is just getting worse,” said Dan Drummond, executive director of the Sonoma County Taxpayers Association. He said he is a lifelong Democrat and voted for Newsom but, like many, has lost confidence that the governor — and government — can address the crisis, so he voted against the bond measure.

No other state has tried as hard as California to attack homelessness. The Newsom administration created an initiative to convert hotels and motels into permanent housing for homeless people. Newsom is asking the Biden administration for permission to providesix months of free rent for homeless people. He launched a Medicaid initiative to provide social services and housing support for those on the streets or at risk of becoming homeless. He has spearheaded new laws to mandate treatment for those with serious mental health conditions.��

So far, Newsom has plowed more than $20 billion into the crisis, with billions more for health and social services. Newsom says at least 71,000 people have gotten off the streets, yet the public health crisis is worsening. Homelessness has risen 20 percent since he took office in 2019, and addiction and mental illness are more rampant, experts say.

In California, an estimated 48 percent of homeless people regularly use hard drugs or drink alcohol heavily, have hallucinations or have had a recent psychiatric hospitalization, said Margot Kushel, a primary care doctor at Zuckerberg San Francisco General Hospital and Trauma Center and a leading homelessness researcher at the University of California at San Francisco.

The missing piece, Newsom told me last week in the Coachella Valley, is Proposition 1. He argued the state desperately needs the bond to fund new treatment beds and permanent housing, which he said is critical for his other health and homelessness initiatives.

“All of this is considered part of this larger mosaic, but the beds are foundational,” Newsom told me.��

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In April, the U.S. Supreme Court will delve into an issue central to the plight of those living in homeless encampments: whether they or slapped with criminal charges for living or sleeping outdoors when there’s no shelter or housing available.

The situation on the streets is causing major political upheaval. In California, Gov. Gavin Newsom (D) is plowing $750 million into clearing encampments — with the elusive promise of shelter — while homeless advocates fight to stop it. But it’s a small city in Oregon called Grants Pass that took the battle to the Supreme Court.

centers on whether it’s cruel and unusual punishment to impose fines and criminal citations for camping or sleeping outside, which is against the law in many cities. Some homeless advocates fear the court’s conservative majority will give carte blanche to state and local officials to sweep encampments in the name of public health and safety.

Newsom is asking California voters to approve a $6.4 billion bond to create thousands of new homeless housing units and behavioral health treatment beds to get people off the streets. But he argued in an that clearing encampments should be allowed and that it can help to unhoused people living in “inhumane conditions,” he said. “The courts have tied the hands of state and local governments.”

He and other public officials also argue that encampments harm public health; a 2016-2018 outbreak of hepatitis A in San Diego linked to homelessness resulted in 20 deaths.

Yet a growing body of evidence suggests sweeps can of people in encampments while causing turmoil in their lives and for the people trying to care for them — potentially costing taxpayer-funded Medicaid programs even more money.

A published last year in JAMA also found that displacing homeless people from encampments can lead to higher hospitalizations — raising health-care costs — and cause serious infections and early death.

“Sweeps prolong homelessness — you can make them disappear from this corner or that corner, but they’re just going to appear somewhere else,” said Eric Tars, senior policy director for the National Homelessness Law Center. “If you want to follow public health approaches, what we need to be doing is getting more people into housing, which evidence shows improves health.”

Sweeps also hurt fragile relationships between homeless people and their caregivers.

“A lot of people on the streets with mental illness live with the fear that anyone who’s trying to help them might get them hospitalized against their will or put in jail,” said Hannah Wesolowski, chief advocacy officer for the . “So when encampments are being cleared by law enforcement, it totally upends people’s lives and violates that trust in a way that they’re going to be more resistant to help.”

But with housed Americans in both parties clamoring for their streets to be safer and cleaner, the health concerns of homeless people aren’t always a priority for politicians.

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Newsom is spearheading , a $6.4 billion bond he says would fund for people living on the streets with untreated mental illness or addiction, and ongoing capacity for 26,700 additional outpatient appointments. It would also alter how $3 billion to $4 billion in existing annual services is spent, funneling a of it into housing.

Many authorities on mental health and homelessness agree California desperately needs thousands more housing units and treatment beds to successfully attack the growing public health crisis. Health and law enforcement groups have lined up behind the initiative, as have the mayors of the state’s major cities.

Homelessness statistics in California have risen a staggering 20% since Newsom took office in 2019, to more than 180,000 people — on the streets and not in shelters. The numbers are growing despite Newsom’s unprecedented investment of more than $20 billion in homelessness programs, plus billions more for health and social services.

Yet many of the front-line workers implementing Newsom’s initiatives fear that Proposition 1 would simply pour more money into a broken homelessness response system that is largely failing to house those in need.

Rather than focus on getting homeless people into mental health and addiction programs — and ultimately into housing — many caseworkers say they waste precious time and taxpayer dollars searching for their homeless clients after encampments have been cleared by state and local officials, a policy Newsom has encouraged, not only for the safety of homeless people but for those in surrounding neighborhoods.

Once they locate their clients, advocates must help them — often repeatedly — obtain food, clothing, and medication refills, and replace official government documents like birth certificates and IDs. “You can’t get housing without that stuff,” said Afton Francik, an outreach worker with the Sacramento-based nonprofit , which is implementing several of Newsom’s homelessness and mental health initiatives.

Perhaps the biggest challenge they face, outreach workers and case managers say, is rebuilding the trust that took time to establish — and which they say is essential to getting people into treatment and housing.

“It makes it so much harder to even find people or help them get into housing because you have to go back and repeat that work you already did,” Francik said.

Newsom says California has placed at least 71,000 people indoors — either in permanent or temporary housing — since he took office in 2019. State money flows to cities and counties, which have opened at least 15,000 housing units and 2,485 residential treatment beds, plus additional outpatient capacity, during his tenure.

Newsom has also revamped health programs to get people off the streets, including a massive $12 billion transformation of the state Medicaid health insurance program that provides some patients with housing and one-on-one case management services.

As he promotes Proposition 1, Newsom is calling for stricter enforcement, saying he feels a deep responsibility to keep California’s streets clean and safe, and to respond to growing neighborhood concerns about trash, mental illness, crime, and drugs. He has acknowledged that sweeps can traumatize homeless people but argues that local officials who receive state money to clear encampments are supposed to find shelter or treatment for those displaced.

Sacramento County Sheriff Jim Cooper, who supports Proposition 1, said sweeps are sometimes necessary for public health and safety.

“This is a huge drain on public resources and emergency services,” Cooper said. “Drugs are everywhere. There is so much mental illness. We’ve got to get these folks the help and treatment they need.”

But critics of the sweeps argue that it’s inhumane to forcibly move people without providing shelter or housing. “We’re seeing a ton of enforcement, but there’s literally nowhere to put people,” said Crystal Sanchez, president of the Sacramento Homeless Union.

Newsom acknowledged the state doesn’t have enough housing for everyone who needs it, and that Proposition 1 is part of the solution. The measure would expand his existing and programs, which do not trigger the land use and environmental reviews that often delay or kill new projects.

“We are in a unique position to take what we have been promoting — these promises — and make them real,” Newsom said in January.

Like all of Newsom’s homeless housing initiatives, Proposition 1 would rely on outreach teams and caseworkers to help homeless people obtain services and housing.

But in boots-on-the-ground interviews from rural Northern California to San Diego, such workers said it would be difficult to get more people into housing if they must continue picking up the pieces after encampment clearings — a policy the U.S. Supreme Court .

The question the court will consider is whether to allow criminal or civil penalties against homeless people living outdoors if no shelter or housing is available. Newsom said that cities and counties should be allowed to clear encampments, signaling he has no plans to retreat from the policy.

“When encampments are being cleared by law enforcement, it totally upends people’s lives and violates that trust in a way that they’re going to be more resistant to help,” said Hannah Wesolowski, chief advocacy officer for the National Alliance on Mental Illness, whose California chapter supports the ballot initiative. “If someone has a mental illness and is unhoused, trust is the most important thing in trying to engage them in treatment and actually getting them into housing.”

Take Samuel Buckles, a longtime Sacramento resident who said he struggles with mental health and is addicted to fentanyl. Buckles, 53, lost his home in a fire and then his job early in the covid-19 pandemic. Since then, he has worked odd jobs as a handyman and purchased a recreational vehicle that he parked around Sacramento and called home.

When law enforcement officials cleared his camp in early February, they confiscated his RV because he had allowed the registration to lapse. He lost his birth certificate and Social Security card, all his medications for diabetes and high blood pressure, his extra clothing, and a fridge packed with groceries he’d recently purchased with his food stamp benefits.

“That was my home and everything I had in the world,” Buckles said on a cold February morning from his new form of shelter: a tent donated by outreach workers.

It was the first time in years he said he had truly felt homeless.

In mid-February, law enforcement cleared the encampment he had relocated to, forcing him to move again. Feeling despondent, he said he had given up on the promise of housing. “Please make this pain stop. I don’t know how much more I can take,” he said.

Buckles was able to grab a few possessions from his RV after it was confiscated, but replacing the documents he needs for housing may take months and repeat visits by outreach workers, said Greg Stupplebeen, an outreach manager with Hope Cooperative.

Even if Buckles had his paperwork in order, “there’s nowhere to put anybody right now,” Stupplebeen told him.

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California está liderando esta tendencia, destinando gran parte de un presupuesto de $12 mil millones a una ambiciosa iniciativa de Medicaid para ayudar a los pacientes sin hogar a encontrar vivienda, y a pagarla para evitar el desalojo.

Arizona está asignando $550 millones de fondos de Medicaid que se usarán para cubrir seis meses de alquiler para personas sin hogar. Oregon está gastando más de $1,000 millones en servicios como asistencia de alquiler de emergencia para pacientes que no tienen un techo.

Incluso Arkansas, un estado predominantemente conservador, destinará parte de unos $100 millones para ofrecer vivienda a sus más necesitados.

Al menos 19 estados están redireccionando dinero de Medicaid —el programa estatal-federal de salud para personas con bajos ingresos— para abordar la creciente epidemia de falta de vivienda en el país, según los Centros de Servicios de Medicare y Medicaid (CMS).

Aunque no hay consenso sobre si esta estrategia proporcionará una solución a largo plazo para la salud o la vivienda de los pacientes vulnerables, la administración Biden está alentando a otros estados a unirse. Varios están en proceso, incluyendo Tennessee, West Virginia y Montana, y obtuvo luz verde del gobierno federal en enero.

El uso de fondos de atención médica para proporcionar vivienda a las personas es “un gran debate filosófico”, dijo Alex Demyan, director asistente de la agencia de Medicaid de Arizona. “Sabemos que la atención de salud no puede resolver todos los problemas, pero también sabemos que las agencias de vivienda están saturadas y que tenemos una enorme necesidad de ayudar a que las personas se estabilicen”.

La falta de vivienda aumentó un 12% en el país el año pasado, con un estimado de , el nivel más alto registrado, incluso cuando aumentó drásticamente el inventario de viviendas permanentes y camas de refugio temporal.

A medida que las personas languidecen en las calles, luchando a menudo con la adicción, afecciones mentales graves y enfermedades crónicas no tratadas, funcionarios de salud y líderes políticos recurren a fondos de salud en busca de alivio. Argumentan que la ayuda para la vivienda mejorará la salud y le ahorrará dinero a los contribuyentes al mantener a las personas fuera de instituciones como hogares de adultos mayores, hospitales y cárceles.

Pero las pruebas que respaldan este argumento son mixtas.

Por ejemplo, en un realizado por investigadores de la Universidad de California-San Francisco, las personas sin hogar del condado de Santa Clara, California, que fueron asignadas al azar para recibir vivienda a largo plazo y servicios, utilizaron el departamento de emergencias psiquiátricas un 38% menos que un grupo de control en un período de cuatro años, al tiempo que aumentó el uso de servicios de salud mental de rutina. Pero aún hubo altas tasas de hospitalización entre los participantes, quienes continuaron dependiendo de la sala de emergencias para atención médica de rutina o para descansar.

Los programas estatales de Medicaid han estado incursionado en el área de vivienda durante mucho tiempo, pero de la administración Biden, están lanzando más servicios para más personas con nuevas y grandes cantidades de fondos estatales y federales.

La tendencia es parte de que alienta a los directores de Medicaid a ofrecer servicios sociales junto con la atención médica tradicional, con el objetivo de hacer que sus residentes sean más saludables.

“Un dólar de atención médica puede hacer más que simplemente pagar una visita al médico o una estadía en el hospital”, dijo a Ģ��ӰԺ Health News Xavier Becerra, secretario del Departamento de Salud y Servicios Humanos (HHS). “Deberíamos estar utilizando el dólar federal de atención médica para la atención preventiva: obtenerla antes de que se enfermen, y mantenerlos saludables. ¿Quién puede negar que alguien que no tiene hogar tendrá más dificultades para mantenerse saludable que alguien que tiene vivienda con agua corriente y calefacción?”, dijo.

Becerra reconoció estas iniciativas como experimentos. Pero dijo que el gobierno federal ya no puede ignorar la muerte y enfermedad que están afectando de manera creciente a las poblaciones sin hogar a lo largo del país.

“Simplemente estamos diciendo, ‘Estado, si puedes demostrarnos que con este dólar de Medicaid mejorarás la salud o el resultado de salud de alguien, entonces has servido efectivamente al propósito del programa Medicaid y le estás ahorrando más dinero a los contribuyentes'”, dijo.

Pero no todos los líderes de atención médica, ni siquiera los expertos en falta de vivienda, creen que esta es la mejor utilización del dinero de Medicaid, especialmente porque el programa enfrenta críticas constantes por no proporcionar atención médica básica a muchos beneficiarios.

“Si estás en Medicaid, a menudo tienes que esperar meses y meses para una visita especializada, incluso si es una preocupación que amenaza la vida, así que me preocupa lo que la gente no podrá obtener debido a esto”, dijo , investigadora de falta de vivienda y médica de atención primaria en el Hospital General y Centro de Trauma Zuckerberg de San Francisco, que trata principalmente a pacientes de bajos ingresos.

“No es que no quiera que se gaste el dinero, pero ¿se gasta mejor en atención médica?”, se preguntó. “Es mucho mejor que nada, pero está lejos de proporcionar la vivienda a largo plazo y la estabilidad que las personas realmente necesitan”.

Kushel dijo que el peligro es que la mayor parte de la asistencia de vivienda de Medicaid se puede utilizar sólo una vez o tiene un límite de tiempo, como los pagos de alquiler, que normalmente finalizan después de seis meses.

“Cuando la gente llega a una vivienda, ya está muy, muy enferma”, dijo. “¿Qué sucede al final de esos seis meses cuando se termina el alquiler gratuito?”.

En todo el país, los programas estatales de Medicaid están ampliando la definición de atención médica y entrando en el negocio de los servicios sociales, brindando una variedad de beneficios no tradicionales, como comidas saludables a domicilio para pacientes con diabetes y filtros de aire para personas con asma.

Si bien históricamente el gobierno federal de Medicaid para pagos directos de alquiler, eso ha cambiado.

En 2022, Arizona recibió la para una iniciativa llamada , que dará prioridad a las personas sin hogar y a aquellas en riesgo de perder su vivienda que tienen una condición de salud mental y una enfermedad crónica. Cuando se lance en octubre, ofrecerá principalmente dos servicios: pagos de alquiler por hasta seis meses; y viviendas de transición, que pueden incluir refugios con servicios intensivos.

Arizona experimentó un aumento del 5% en el número de personas sin hogar en 2023 con respecto al año anterior. Su programa complementará una iniciativa independiente de Medicaid financiada por el estado que proporciona 3,000 bonos de alquiler para personas del sur de Arizona que padecen una afección mental grave y no tienen hogar, o están en riesgo de quedarse sin hogar. Unas 5,000 personas están en lista de espera para recibir estos bonos.

“Hemos visto resultados de salud muy positivos, y por ende reducciones de costos, por lo que para nosotros tuvo mucho sentido ampliar nuestro trabajo a ese espacio”, dijo Demyan. Ese programa redujo las visitas a emergencias en un 45% y las admisiones en hospitales en un 53% a los seis meses después de que los pacientes comenzaron a recibir servicios, al tiempo que aumentó la atención preventiva menos costosa en un 56% y se ahorró $4,300 por miembro, por mes, según .

California, hogar de casi el 30% de la población sin techo del país, experimentó un aumento de casi el 6% en el número de personas sin hogar en 2023, llegando a cerca de 181,000 personas.

El estado lanzó su enorme iniciativa CalAIM en 2022 para ofrecer una amplia variedad de servicios sociales a una pequeña porción de los aproximadamente 15 millones de del estado. Una gran parte de los recursos se destina a servicios de vivienda para personas sin hogar o que enfrentan un desalojo, como cubrir depósitos de seguridad y contratar administradores de casos para buscar apartamentos disponibles.

Líderes estatales también están pidiendo permiso a la administración Biden para proporcionar seis meses de alquiler.

“Si uno carga con una gran cantidad de problemas de salud física o conductual, ya sea diabetes o VIH, presión arterial alta o esquizofrenia, y no tiene vivienda, es realmente difícil estabilizar esas condiciones”, dijo , secretario de la California Health and Human Services Agency.

Pero advirtió que el enfoque central de Medicaid debe seguir siendo lograr que las personas estén sanas, incluso si viven al aire libre, lo cual es un desafío monumental y costoso porque afecciones como la diabetes, las enfermedades cardíacas y el VIH requieren un tratamiento continuo y, a menudo, múltiples medicamentos.

“No creo que la atención médica sea responsable de resolver la situación de las personas sin hogar en California ni en ningún otro lugar”, dijo Ghaly. “Pero si la inestabilidad o la falta de vivienda es uno de los factores clave que obstaculizan la salud, entonces es absolutamente necesario que le prestemos atención”.

Las aseguradoras de salud que brindan cobertura de Medicaid en California pueden elegir si ofrecen servicios de vivienda, pero Oregon exige que las aseguradoras de Medicaid lo hagan.

La falta de vivienda aumentó un 12% en el estado entre 2022 y 2023, pero Oregon se centra en los pacientes en riesgo de quedarse sin hogar. Los participantes serán elegibles para seis meses de alquiler y otros servicios cuando el programa se lance en noviembre, dijo Dave Baden, subdirector de la Oregon Health Authority. “Realmente estamos tratando de centrarnos en las personas que están al borde del abismo”, dijo Baden. “Si ya no tienes hogar, realmente necesitas más dinero, y por más tiempo, para mantener a esa persona con vivienda”.

No sólo los estados están experimentando con este enfoque. El sistema de salud Kaiser Permanente ha invertido sus propios fondos en vivienda. En los últimos años, el gigante de la atención médica ha comprometido cientos de millones de dólares para ayudar a mantener o construir miles de unidades de vivienda asequibles, además de brindar a sus miembros beneficios de Medicaid relacionados con la vivienda.

“Tenemos que hacer algo. La crisis está fuera de control”, afirmó , su director de salud. , profesora de la Universidad de Nueva York y ex funcionaria de la administración Obama, experta en economía de la atención médica, advirtió que el de instituciones de atención médica al negocio de los servicios sociales podría ser una “distracción peligrosa”.

Glied señaló que al menos 57 sistemas de salud y 917 hospitales en todo el país han lanzado iniciativas de servicios sociales, la mayoría centrándose en la vivienda. Debido a que muchas instituciones luchan por cumplir con los estándares de seguridad del paciente y atención de calidad, Glied argumentó que deberían mejorar la atención básica y dejar la vivienda a organizaciones de servicios sociales “que se especializan en este trabajo”.

Peter Lee, otro ex funcionario de la administración Obama y director ejecutivo fundador del mercado de seguros del Obamacare en California, dijo que los proveedores de atención médica deberían considerar ofrecer algunos servicios sociales y de vivienda, pero teme que tales iniciativas puedan desviar dinero de la medicina tradicional e impedir que los pacientes reciban una atención adecuada.

“En los últimos cinco a 10 años, se ha reconocido ampliamente que la salud es mucho más que la atención médica real. Es muy cierto”, dijo Lee. “La pregunta es cómo abordar esos problemas mientras la atención médica en sí no está funcionando demasiado bien. El objetivo principal de esto es garantizar que las personas con diabetes reciban una excelente atención, y que puedan tener los chequeos regulares que necesitan”.

Los programas estatales de Medicaid, que brindan atención a cerca de , a menudo tienen dificultades para , como visitas pediátricas al dentista y exámenes de detección de cáncer de mama.

En California, el estado que gasta más en servicios de vivienda, los niños con Medicaid no tuvieron acceso oportuno a atención de salud mental o de adicciones en 2022, según una publicada en noviembre.

A pesar de estas deficiencias, la mayoría de los estados que han recibido el visto bueno federal para experimentar con servicios de vivienda han obtenido financiación para cinco años. California se encuentra entre los estados que esperan que los beneficios sean permanentes.

Aunque una presidencia republicana podría interrumpir esta tendencia, los estados dicen que están comprometidos, incluso si sus iniciativas no pasan un .

“El enfoque particular en el retorno financiero de la inversión no es tan claro como lo era antes”, dijo , directora federal de Medicaid durante la presidencia de Obama.

“Los estados simplemente están viendo el poco sentido que tiene tratar a las personas y luego devolverlas a las calles sin el apoyo que necesitan”.

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