Voice of San Diego is part of the Mental Health Parity Collaborative, a group of newsrooms that are covering stories on mental health care access and inequities in the U.S. The partners on this project include The Carter Center, The Center for Public Integrity, and newsrooms in select states across the country.
A state law set to take effect in January aims to make it easier to force Californians with severe substance use disorders into treatment that is now often not immediately available to San Diegans who want it.
Gov. Gavin Newsom last month signed SB 43, which broadens eligibility for both conservatorships and shorter-term involuntary holds in hospitals to include people whose addiction challenges threaten their own safety and access to necessities including medical care.
While much of the rhetoric around SB 43 implied longer-term conservatorships, San Diego County’s behavioral health director and others predict the law’s most dramatic initial impact will be a spike in instances where police bring people struggling with addiction to hospitals on short-term holds.
Whether SB 43 results in the majority of those patients receiving continued addiction treatment will rest on hospitals’ ability to quickly make those connections. For now, care often isn’t available on demand for people with Medi-Cal insurance.
This means that absent a rapid influx of new treatment options and other reforms, the law could lead more low-income and homeless San Diegans to cycle through hospital emergency rooms without accessing the care they desperately need.
The lobbying group for San Diego’s hospitals is urging county supervisors to pull a lever in the state law allowing for an up to two-year postponement to prepare for a potential wave of people flowing into ERs and ensure treatment is available.
Spokespeople for county supervisors including Chairwoman Nora Vargas declined to comment on whether they’d make that move.
Mayor Todd Gloria and other champions of the conservatorship reform law argue that vulnerable San Diegans and their loved ones can’t wait for the controversial new tool – and that lives are at stake. They believe the mandate is needed to make more care available.
People with substance use disorders have long faced disparate treatment when they end up in the hospital, including on short-term holds that last for up to 72 hours.
Once medical staff recognize that a person’s primary symptoms are tied to substance use, they often move to discharge them once they’re no longer intoxicated. Hospital workers usually deem these patients ineligible for longer-term conservatorships requiring sign-off from a judge because they don’t consider them gravely disabled or a harm to themselves or others once they sober up.
Some people repeatedly end up in ERs, never accessing the care they need.
SB 43 changes how temporary holds play out for patients with severe substance use disorder by making the condition eligible for a conservatorship and thus, perhaps a longer-term hospital stay. It also broadens the definition of gravely disabled to include a person’s inability to ensure their own personal safety or “necessary medical care” rather simply food, clothing or shelter.
Luke Bergmann, the county’s behavioral health services director, thinks SB 43 is unlikely to fuel a surge in longer-term conservatorships for people with addiction challenges. He does expect a spike in people ending up in the ER on a temporary hold for that condition.
Bergmann said that short ER stay could present an opportunity – if the system can swiftly deliver needed care. He acknowledged short-term holds could also simply disrupt lives and result in more disillusionment if those patients don’t get linked to other care.
“I think the broader opportunity is how do we collectively try to shift the likelihood of connection to care being greater than the likelihood of disruption in well-being,” Bergmann said. “And the context for that is the overwhelming majority people with substance use disorder never get access to care – ever, in their lives.”
Indeed, the federal Substance Abuse and Mental Health Services Administration’s 2021 national drug use survey found 94 percent of people 12 and older with a substance use disorder didn’t receive treatment that year.
For now, San Diego’s behavioral health system is often unable to rapidly deliver care to the fraction of the population struggling with addiction who desperately want it. It also struggles to deliver for mental health patients who need long-term care or housing.
San Diegans with Medi-Cal insurance often wait weeks for residential addiction treatment or a detox bed. Others languish in hospital beds for weeks and even months waiting for longer-term programs such as mental health rehabilitation facilities. Board-and-care homes, housing that comes with ongoing support, are often unavailable. People who have challenges such as such as incontinence, cognitive impairment or mobility limitations – conditions that mean they are also more likely to be deemed gravely disabled – or mental health diagnoses paired with substance use disorders often struggle to find landing places that meet their needs.
While outpatient programs can be easier to access, they often require follow-through and support that particularly vulnerable people struggling with addiction can’t always muster. Patients can sometimes wait days for an orientation appointment.
Medication-assisted treatment, which eases the process for some substance users to start the recovery process, is also more readily available but experts say it may not be the silver bullet solution for someone who doesn’t have a stable home or support system or has a slew of other challenges. It also isn’t a workable solution for all types of addiction.
And though it’s unclear what the demand for it might be under SB 43, the county also doesn’t have locked treatment programs for people whose primary diagnosis is a substance use disorder. The county also doesn’t have any contracts with chemical dependency hospitals for people with substance use disorders who have Medi-Cal insurance, facilities some providers are convinced are needed for substance use patients who need medical support – or are deemed gravely disabled.
“I don’t know where they would go,” said Nathan Smiddy, a project manager for the Harm Reduction Coalition of San Diego who is in recovery and has helped countless people struggling with addiction. “It’s almost like that bill’s word salad for people that want a solution to the issue.”
Smiddy, like civil liberties activists statewide, doesn’t believe people should be forced into addiction treatment. He believes leaders across the state should instead be asking people struggling with addiction what treatment services would best serve them.
“Why aren’t we listening to them?” Smiddy said. “We don’t do that.”
Smiddy is among a chorus of advocates and providers statewide who have emphasized that the new law fails to confront the reality that people with substance use disorder who are clamoring for treatment now often can’t get it.
The lack of options has also led the Hospital Association of San Diego and Imperial Counties to call on county supervisors to delay implementation of SB 43 to give the county, police, hospitals and service providers more time to prepare. The lobbying group fears an influx of short-term holds at a time when they are grappling with packed ERs and adjusting to CARE Court, a new state court system to compel people with psychotic disorders into care.
“Two months is an incredibly short time frame to ramp up a program that comes with no additional funding,” Hospital Association CEO Dimitrios Alexiou wrote in a statement. “We need more services in place to be able to meet the need of those who qualify for conservatorship.”
Tri-City Medical Center in North County argues an additional crush of people flowing into ERs could also affect other patients.
“Without funding to support this mandate, while well intended, this will again constrain already precious resources such as emergency department capacity, and will negatively impact anyone seeking emergency room care,” the hospital wrote in a statement.
Newsom and state lawmakers say they are working to deliver resources to bolster treatment and housing options for people with behavioral health challenges. In March, California voters will weigh in on Newsom’s $6.4 billion bond proposal to expand options for people with both mental health and substance use conditions and a request to allow funds from an existing state millionaire’s tax to be used on services for people with substance use disorder.
Newsom and Gloria, who has rallied behind statewide conservatorship reform, say the state can’t wait for those funds and infrastructure to materialize to start compelling vulnerable people who might otherwise die on the street into care.
Gloria likens conservatorship expansion to the state’s longtime commitment to deliver public education, which ensured ongoing investment.
“I think absent this mandate to actually care for these severely mentally ill people we’ll continue to lack beds,” Gloria said. “The passage and the creation of more responsibility to care for these kinds of folks will mean that communities up and down the state are gonna have to accommodate them.”
Dr. Aaron Meyer, a UC San Diego psychiatrist who is the city’s first behavioral health officer, has a similar perspective.
Meyer, who has worked in UCSD’s Hillcrest ER, said he has seen a slew of patients leave the hospital after a temporary hold because their primary challenge is substance use disorder. Many of them have had a handful of serious health conditions exacerbated by their addiction – and an inability to address their addiction on their own.
If that same person’s primary challenge was a mental health condition, Meyer said, they could be held and potentially move into a long-term rehabilitation facility, something that doesn’t now exist for people with substance use disorders. He’s adamant that people struggling with addiction should be eligible for more care and that outside pressure will be needed to make it happen.
“Until we have something that’s going to force the issue, I think we’re going to remain in a broken status quo,” Meyer said. “I think this is a wake-up call.”
Meyer is hopeful that SB 43 will lead the county to invest in more substance use treatment options and to ensure that patients can more seamlessly be linked with existing programs so forced hospitalizations result in connections to treatment that can help them over the long haul.
Caroline Stewart, a psychotherapist whose adult son has struggled with both severe substance use and mental health conditions, is also hopeful. Stewart’s son has grappled with homelessness and the criminal justice system as she and her husband have tried to help him get care that addresses his needs. Having a serious mental illness and a substance use disorder is common but Stewart said it’s difficult to find programs that address both challenges.
She thinks SB 43 will force change.
“It will literally be illegal to abandon these people. It will not be legal,” Stewart said. “That will force beds. There will have to be beds.”