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California prop T, demanding treatment on demand
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Constant Readers,
I don’t think it’s intentional, but the Election Commission did a great job of creating mnemonics for this November’s ballot. Prop S is Set-asides, Prop R is Renaming the Oceanside Water Treatment Plant, Prop A is Ash(i)tload of bond money etc...
And Prop T is Treatment on Demand.
Specifically, Prop T would require the Department of Public Health to "maintain an adequate level of free and low cost medical substance abuse services and residential treatment slots commensurate with the demand for these services." (Text here: Download 2008_prop_t.pdf.)
It has taken me a while to write about this one because I’m really torn. Here’s the quick and dirty: treatment on demand for substance abuse is good. Really good. But Prop T basically creates an unlimited set-aside based on dicey information. So I think the question becomes: is the need for treatment funding so dire that we must do something – even if it means passing something shoddy and muddling through it? That’s for each person to decide, but to keep you informed, here are 10 Q and A’s related to Prop T.
1. What is “Treatment on Demand”?
According to a 1999 UCSF study on this issue, treatment on demand is "a policy that supports immediate entry into drug treatment for all requesting it. Timely access to treatment contrasts with policies and emphasize punishment or interdiction." (Here's the study - we'll refer to it again: Download treatment_on_demand_study.pdf.)
It doesn't take a psych major to explain that waiting for treatment seriously decreases the possibility that the person will follow-through with the program. I can barely follow-through with a gym membership. If I had to wait to go? Oh man, fuggetit.
2. A little history? (Okay, that's not really a question, but this part it important!)
Treatment on demand has been a City policy since 1996, when the Board passed a resolution endorsing "the goal of substance abuse treatment on demand for indigent San Franciscans" and "urg[ing] the Mayor, the Health Commission and the Director of Public Health to plan for and provide full funding...for substance abuse treatment services on demand for indigent San Franciscans.” (Resolution here: Download 1996_treatment_on_demand.pdf.)
Apparently, that "urging" led to insufficient efforts.
3. What were those efforts?
Pretty damn heroic, actually. At the July 10 hearing on Prop T at the Rules Committee, Deputy Director of Community Behavioral Health Services for the Department of Public Health, Dr. Alice Gleghorn, gave the following information about what has happened since 1996:
- There has been a more than 200% increase in local funding specifically for substance abuse ($32 million in FY 1996-97; $62 million in FY 2007-08.).
- Since 1996, the number of substance abuse treatment slots has increased more than 53% primarily due to increases in outpatient and methadone maintenance treatment.
- There has been a 28% increase in the number of addicted clients served annually.
- The number of homeless getting into treatment services has increased by 30%.
- There has been a 900% increase in substance abuse services provided in jail.
- Drug-related deaths in SF have decreased despite a nationwide increase. We used to have one overdose death every other day, and is now less than 100 per year.
Ms. Gleghorn also put together an excellent powerpoint on the trajectory of treatment on demand in San Francisco. (Pwp here: Download treatment_on_demand_powerpoint.pdf.)
4. Why do we have Prop T now?
The text of Prop T says that, "Substance abuse treatment services are a key component to San Francisco's Continuum of Care Plan, the official homeless policy of the City and County of San Francisco." The continuum of care plan is art of the recently-released "Five Year Strategic Plan of the San Francisco Local Homeless Coordinating Board." That report came out earlier this year and the Board of Supervisors adopted the report as official city policy on February 26. Mistermayor signed on February 29.
Now, obviously substance abuse treatment is important to ending homelessness. But so are a buncha other things. For example, the report spends a lot more time discussing mental health and employment than substance abuse. Of 6 broad initiatives in the Plan, substance abuse treatment is only a small part of number 4. (Report here - be forewarned, it's a big file: Download strategic_plan.pdf.)
Not that there's anything at all nefarious about it, but I suspect that Prop T is related to this year's Community Justice Center debate. Folks are concerned that the CJC (which promises to provide social services to SF residents arrested in the Tenderloin for misdemeanors and nonviolent felonies) was coming into being at the same time that social services were being cut. It appears that Prop T was put forth to ensure that substance abuse services are always available to arrested folks and beyond. Also, according to committee testimony, to help people before they commit crimes.
5. Is it a set-aside?
Prop T is an ordinance that would amend the City’s Administrative Code. However, technically, the City Charter controls the budget process. So, unless you amend the Charter, there is no requirement that the money mandated by Prop T will be made available. Remember though, that we have other funding requirements created simply by ordinances (the Firehouse Act and Care Not Cash) that, while not legally binding, always get funded because no on wants to be the jerk who refuses to fund a publicly endorsed initiative. So, that’s a long way of saying: because it’s not a Charter amendment, it’s not set in stone like a Charter set-aside, but if endorsed by the voters, it will likely effectively be a set-aside.
Note that I couldn’t find any other example of a funding mandate either in the City Code or Charter that ties money to “demand” or “whatever we feel like” or “until we run out of money”. The open-ended nature of the amount of money we’re looking at with Prop T appears to be a first.
6. What are some of the potential problems with Prop T?
Prop T requires us to fund and maintain medical (basically Methadone) and residential substance abuse facilities that are commensurate with demand. (Note that Prop T does not address other outpatient treatment.) So, the crux of the proposal is the definition of “demand.” The ordinance gives us the following (unhelpfully obvious) definition:
“Demand shall be measured by the total number of filled medical substance abuse slots plus the total number of individuals seeking such slots as well as the total number of filled residential treatment slots plus the number of individuals seeking such slots.”
So, how do we know how many people are “seeking” such slots? The DPH will probably have to rely on waiting lists. Easy enough, right? Wrong. The 1999 UCSF study (above, Q1) set out to see if increased funding for treatment led to a decrease in waiting times. They couldn’t make a direct connection – not because it didn’t exist – but because the data from the waiting lists was to screwed up to be useful.
Most all substance abuse programs in the City are run by nonprofits, which may or may not properly to report waiting list data. Also the state database that tracks waiting list data only records information from institutions that receive state or federal funding. And it didn’t use individual identifiers, so you couldn’t know if the same person was on the list for multiple programs. Nor could you know if someone on a certain waiting list already got in somewhere else. Unless there have been some serious upgrades to how we track people on substance abuse treatment waiting lists - and it includes nonprofits that don’t receive outside funding - this promises to be a cluster.
7. Do we know how much Prop T will cost?
The Controller's office estimated that Prop T would cost the City anywhere between $7 and $13 million in addition to the $50 million we already spend to provide free and low cost substance abuse. According to the report, "These services are almost entirely delivered through contracts with local nonprofit organizations." (Report here: Download controllers_report.pdf.)
Proponents of Prop T point to a 1994 study conducted by folks at Berkeley which found that every dollar spent on substance abuse treatment results in $7 in savings on things like jail, emergency room visits, etc. (I am sure it exists but couldn't find it. Will gladly link to it if someone can send it to me.)
8. Why isn’t this a Charter amendment?
Here’s how it works: the Mayor, four members of the Board of Supervisors or a bunch of citizen signatures (the number required varies) can put an ordinance on the ballot. However, if you want to put a Charter amendment on the ballot, it has to be voted on at the Board of Supervisors. And it has to get a majority. It may be the case that the reason Prop T is an ordinance is because it couldn’t get six votes at the Board. (It was put on the ballot by the signatures of Supervisors Daly, McGoldrick, Mirkarimi, and Peskin.)
9. Does it have to be on the ballot?
Not really. As an ordinance, it could have been passed at the Board, but even if Prop T could get a majority at the Board, I’m betting that Mistermayor would veto it. Which requires 8 votes to override. And it is doubtful that there is that much support at the Board. Plus, this way it gets to sit right next to Prop L – see question 4.
10. Most interesting exchange from the Rules Committee hearing on Prop T?
DPH Deputy Director, Barbara Garcia: "...if we can't take on a cut in substance abuse, we'll have to cut in other areas. And that would be one of the challenges that we have with the act. But overall we believe in treatment, we do not want to cut substance abuse treatment but because of the general fund burden there we are forced to do that every year..."
Supervisor Daly: "If you try and cut something else, we'll just do this again for that."
At the end of the day, I would be very surprised if Prop T didn’t pass. (While groups like SPUR and Plan C have recommended a "no" vote, there aren't any arguments against it in the voter pamphlet.) On the one hand, it’ll get the vote of the people who think the City can fire up our dream-fueled printing press that makes money out of Unicorn horns using ink made of fairy dust. It'll also get the votes of those who would gladly authorize millions to fill the fountain at Civic Center Plaza with Methodone and Antabuse if it would keep folks from urinating on their front porch. Some folks in between, too.
--Melissa
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