Sonoma County passed up opportunity for millions of dollars to fund substance abuse treatment for low income residents

As 2018 dawned, Sonoma County was on the verge of joining a state program that could have delivered tens of millions in federal and state dollars to pay for an extensive array of substance abuse treatment services for low-income residents.

An agreement, dated Jan. 9, was sent to the county Department of Health Services and awaited only the approval of county supervisors and the signature of Barbie Robinson, the department’s director at that time. It projected the county would receive $38.6 million through fiscal years 2017-18 to 2019-20 to fund treatment services.

Documents obtained from the state Department of Health Care Services by The Press Democrat show the approval was eagerly anticipated by health department staff members who had begun working on the application three years earlier, in 2015.

In an email responding to a Dec. 19, 2017, inquiry from the state about when the county would be able to initiate the program, David Sheaves, an administrative services officer with the behavioral health division, wrote: “We are looking at an April 15, 2018 start date. We will do everything in our power to start sooner but, realistically, 4/15/2018.”

Three weeks later, on Jan. 9, after receiving word from the state that a quick turnaround was needed to achieve the April 15 start date, Sheaves responded: “I will push this one through as fast as humanly possible on our end … THANK YOU!!!!”

But Robinson never took the agreement to the supervisors for their approval, and never returned a signed agreement to the state. The moment passed, and with it millions of dollars that could have supported drug and alcohol treatment services for lower-income residents.

Now, with the deadly toll of drug and alcohol use — driven in recent years by an epidemic of opioid addiction — still reverberating nationwide, the Department of Health Services has applied again to join the program.

The department’s application is centered on an implementation plan that closely resembles the one it used in its previous application. One difference is that this time around the plan notes: “There has been a greater than expected increase in unintentional drug overdoses and the overall death rate due to drug overdose has increased significantly in the past several years.”

‘A massive error’

In an interview for this article, Shirlee Zane, a member of the county Board of Supervisors in 2018, said that the failure to move forward with the program “was a massive error on behalf of the county.”

“The county dropped the ball,” Zane said.

Robinson left the county in May 2021 and is now executive director of the Harris County Public Health agency, in Texas. She declined a request for an interview to discuss why the department did not proceed with the program. Neither she nor the agency’s communications staff responded to a second request.

Sheaves, who no longer works for Sonoma County, declined to comment for this article.

Tina Rivera, who joined the department as assistant director in 2020 and replaced Robinson as health services director, said the process was more than just a simple matter of signing a contract and picking up a check.

At the time, the county’s behavioral health division was in a financial crisis and facing steep budget cuts. In order to roll out and support the program, the county would have had to spend money it could not afford, Rivera told The Press Democrat in an interview.

“It could have completely annihilated and destroyed the Department of Health Services because without that upfront investment, it would not have worked,” she said.

"Behavioral health had fallen off of a fiscal cliff. So when you're faced with a financial hole or deficit, unfortunately, there is missed opportunity. Without that upfront capital or without stability and infrastructure, we can have great programs all day long, but without a solid infrastructure, those programs are going to fall apart,“ Rivera said. “Without that financial investment, it was impossible to opt into (the program) at that time.”

However, the department’s application to the program — which The Press Democrat obtained through California Public Records Act requests — included a fiscal plan that won approval from the state and federal governments. The plan detailed how the county would finance staffing and match funding to successfully participate in the program. Additionally, the program also makes state funds available to help counties cover local matching costs.

Supervisor James Gore, chair of the Board of Supervisors in 2018, said, “I was not made aware of the opportunity. It’s hard for me to judge the situation void of the context” that Robinson could have offered. “I would have loved to have been made aware of all information including this program. However, I cannot offer retrospective judgment.”

Robinson, Gore added, “did exemplary work in solving our fiscal crisis during those years.”

Program led to greater access elsewhere

Sonoma was the 14th county approved for the program, according to the state. Six and a half years after it failed to move forward, 37 out of 58 California counties are enrolled, reaching 96% of state residents who are eligible for it. Riverside County was the last county to join, in 2021.

Commonly referred to as Drug Medi-Cal, or DMC-ODS, the program is a 2015 California initiative that expanded upon the federal Medicaid program for low-income people to improve access to substance abuse treatment.

Participating counties can use those dollars to pay for dramatically increased levels of residential substance abuse treatment as well as expanded narcotics treatment programs. They can also fund case management, outpatient and recovery services, physician consultations and more medically assisted treatment options, among other modes of care they could not previously use Medi-Cal dollars for.

Annual audits of the program and other evaluations have shown a range of improvements and show access to services increased markedly in participating counties while repeat overdoses declined sharply.

The program resulted in a 20% overall increase in access to substance abuse treatment in counties that adopted it, according to Brittany Bass, a UCLA economist who, as part of the mandated audit process, analyzed the program for a 2023 research paper. For residential treatment services, the program led to a 25% increase in access.

UCLA study 2023 publication.pdf

“The increased ability to draw down federal Medi-Cal revenue for the continuum of substance use services enabled (Marin) county and contracted partners to enhance existing services, implement new programs and support greater client choice and access to high-quality, culturally responsive services,” Todd Schirmer, director of Marin County’s Behavioral Health and Recovery Services, said in an email.

Millions in funding

It’s impossible to know for sure how much money for substance abuse treatment programs Sonoma County might have realized had it started the program in 2018 and continued with it for the last six years.

For one thing, counties can only bring in DMC-ODS funds based on services they provide; so they might not bill the state for the maximum they qualify for if they provide fewer services than initially projected.

Take the nearby counties of Marin and Napa.

Marin County was the third county to opt in to the program, in 2017. Its initial agreement covered three years and projected it could receive $14.7 million over that period. The county billed for approximately 80% of that amount, officials said.

Since starting the program, Marin County has received $2.5 million to $3 million annually in federal funding through DMC-ODS, officials said, while spending about $500,00 a year in local matching funds.

Napa County’s agreement said it was eligible for $18.5 million between fiscal years 2017-18 and 2019-20. Since it joined the program, the county has received $12 million in Medi-Cal funds through the program. The county’s budget for alcohol and drug services was $8.2 million last year.

However, other counties comparable in size to Sonoma County have brought in tens of millions of dollars from DMC-ODS.

Solano County — with a population of 448,747 compared to Sonoma County’s 482,650 — was projected to receive $20.3 million between the 2020-21 and 2022-23 fiscal years. The county received $19 million, officials said.

Santa Barbara County — with 443,837 residents — was projected to get $53.7 million over its first three years in DMC-ODS. Over four years, the amount it has billed for has risen each year, with $47.7 million approved so far out of $49.2 million claimed. Over that time, it has provided $8.7 million in local matching funds.

And Monterey County — with a population of 432,858 — was projected to receive $26.6 million over its first three years. In 5¼ years, the county has billed for $40 million.

Overall, to date, the state has reimbursed California counties approximately $3.4 billion in federal, state and local funds as part of DMC-ODS, including for the cost to counties of administering the program, according to the Department of Health Care Services.

“Given the amount of money that was on the table, that certainly merits a conversation with the board at a public meeting, and that would have been an appropriate step to take,” said Sonoma County Supervisor Lynda Hopkins.

Early in her board tenure,“ Hopkins said, she learned about DMC-ODS from Robinson and that it was “on the horizon, it was going to be implemented.”

But she never knew about the final agreement the state sent to the county for Robinson’s signature, Hopkins said.

Supervisor Susan Gorin said she didn’t have enough information to comment.

Boosting treatment infrastructure elsewhere

Since passing up the program, Sonoma County’s substance abuse treatment infrastructure has been dramatically thinned, and the number of people who receive treatment each year has declined sharply.

In 2017, there were 202 residential treatment and detox beds that the county contracted for, according to documents submitted that year as part of Sonoma’s DMC-ODS application. Today there are 48 in the county and about 14 beds in facilities in other counties that the department contracts with — overall, a 69% decrease in available beds.

Another marker of change: In the 2018-19 fiscal year, there were 850 admissions into residential treatment at providers with whom the county contracted for services.

By the 2022-23 fiscal year, that number had dropped to 246, according to county records obtained by The Press Democrat through public records requests. That’s a 71% decrease in client admissions. And of those 246 admissions, 117 were to providers out of Sonoma County.

In other Sonoma County measures:

• There were 1,918 admissions to detox services in 2018-19; there were 893 admissions in 2022-23, a 53% decrease.
• There were 1,259 admissions to outpatient treatment in 2018-19; there were 417 in 2022-23, a 67% decline.
• There were 746 admissions to case management services for substance abuse treatment in 2018-19; in 2022-23, there were 275 admissions, a 63% decline.

The opposite happened in Marin, Napa and Solano counties after they joined the program.

In Marin, in 2015, there were 10 facilities either run by the county or that the county contracted with offering substance use treatment services for low-income residents. In 2022, there were 18, an increase that officials attribute to DMC-ODS. Also, before joining the program, Marin contracted for residential treatment at two sites; today, the county contracts with 10 residential treatment providers.

Meanwhile in Napa and Solano counties, data show an increasing number of residents are being served through the program every year.

‘Upward trend’

In Napa, the county “continues to see an upward trend in number of clients served year over year” through the program, said Jennifer Yasumoto, director of the county’s Health and Human Services department.

For example, she said, in fiscal year 2018-19, 339 clients received DMC-ODS services. In calendar year 2021, 449 clients were treated through DMC-ODS. That number rose to 597 in 2022, a 33% rise in just one year.

Solano County is one of seven counties including Mendocino and Humboldt in a joint DMC-ODS plan managed by the nonprofit Partnership Health Plan. In Solano, unique users of DMC-ODS-funded substance abuse treatment services rose from 1,143 in 2020-21, the county’s first year in the program, to 1,406 last fiscal year. Also, primary care visits for medically assisted treatment services through the DMC-ODS program rose from 4,923 in 2020 to 21,043 in 2022.

Another finding by UCLA researchers: in counties belonging to the Partnership Health Plan program, DMC-ODS led to a 30.6% decrease in the chance that someone who overdosed before the program took effect would overdose again after DMC-ODS was implemented, compared to counties that did not implement it. However, in counties like Sonoma that had not started the program, the chances that someone who had already overdosed would overdose again rose 28.5%, to 23.16%, during the same time period.

Researchers also found that without treatment, someone who overdosed in the Partnership Health Plan counties before DMC-ODS went into effect had a 9% probability of overdosing again. But with the treatment available through DMC-ODS, that probability dropped to 2%. (In non-DMC-ODS counties, the probability that someone would re-overdose was 19.4%.)

In addition, DMC-ODS claims paid by Partnership Health Plan on behalf of Solano County climbed from 48,248 in 2020-21 to 140,289 last fiscal year.

“You're leaving money on the table if you don't opt in to the program, money that is available to help your constituents,” said Hector Hernandez-Delgado, a staff attorney with the National Health Law Program and an expert on the program. “It has saved lives.”

Applying again

Last April, Rivera, the health services director, her staff, and a former behavioral services director, Bill Carter, who is consulting on the DMC-ODS application, told supervisors the program would have a major impact on the local landscape for substance abuse treatment.

“This DMC-ODS option does allow us to draw down critical funds … to be able to pay for services like residential treatment,” said Melissa Struzzo, Substance Use Disorder Services Section Manager at the county’s Behavioral Health division.

“That would greatly give us opportunity to expand our current service provision here around residential treatment and other services in our county for substance use disorder,” Struzzo said.

"Will that provide resources for us to reestablish substance abuse inpatient treatment in Sonoma County?“ asked Chris Coursey, the board chairperson.

“Absolutely,” Rivera said.

Carter’s presentation projected the program coming online in mid-2024.

He told the supervisors that the estimates for how much the county would bring in from the program amounted to $4.46 million annually, and that it would have to provide $766,000 in matching funds (some of which, according to program administrators in other counties, is provided through state general fund dollars).

“A relatively small local investment has a large payoff in terms of state and federal funds to the county,” he said.

'All the wonderful things’

Why did the county pass on joining the program in 2018?

Zane said she didn’t recall Robinson bringing the state’s approval to the attention of the board at the time. It’s possible, Zane said, that it got lost in the full-time task of dealing with the immediate aftermath of the deadly Tubbs and Nuns fires, which had swept into the county the previous October.

A review of Board of Supervisors’ agendas for all of 2018 turns up no items related to the DMC-ODS program or the agreement sent by the state.

Supervisor David Rabbitt, though, said he does “distinctly” recall some sort of board level discussion taking place with Robinson, perhaps at a budget presentation.

“I certainly was privy to those conversations and understood the reasons why the county at that time had different priorities and a lack of ability to spend the amount of time needed to institute that program and continue to run everything else that was in the air,” Rabbitt said, adding, “I do give deference to our subject matter experts.”

Regardless, as the county moved toward its approval, talk of the program was spreading through the world of substance abuse treatment providers, said Susan Hertel, who retired in 2022 as regional director from Drug Abuse Alternatives Center, the county’s largest provider of inpatient and outpatient treatment services.

“In 2017, I went to a meeting and we talked about rates and all that and the changes it would bring and all the wonderful things,” Hertel said. “Then Mike Kennedy left and I don’t know what happened at the county.”

Kennedy, then director of the behavioral services division, drove the DMC-ODS application process. And it was Kennedy who received a Feb. 27, 2017, congratulatory letter from the state when the county’s implementation plan was approved, crossing a critical hurdle in the application process.

But in March 2018, two months after the state sent the county the DMC-ODS contract for Robinson to sign, Kennedy went on paid administrative leave. He resigned in good standing that April after reaching a settlement deal with the county.

His departure followed a monthslong campaign by Robinson to narrow the Department of Health Services budget deficit (estimated at the time to be from $11 million to $19 million) through steep cuts to mental health and substance abuse staff.

Robinson, who was Kennedy’s boss, said inaccurate revenue projections, increasing costs and declining revenue led to perennial budget deficits in the behavioral health division. At the time, Kennedy was reportedly resisting many of the proposed staffing cuts.

Kennedy declined to comment for this article, saying he was prevented from doing so by his exit agreement with the county.

Carter, the former behavioral health chief who is now consulting with the county on DMC-ODS, echoed Rivera, saying the county just could not afford to join in 2018.

“I would say that one of the financial problems that the county had before I got there is that they were betting on future income a lot,” he said in an interview for this story.

“The county would have had to spend a significant amount of its own funds, realignment and general fund, to bring up (DMC)-ODS. And at the point we were trying not to cut core services to which we were already committed, so we couldn't expand, we didn't have any more discretionary funds to expand ODS,” Carter said.

Carter said the decision to not move forward with DMC-ODS occurred before he joined the department and he did not know if the agreement had ever been taken to the Board of Supervisors for its review.

“Throughout my tenure, DHS had ODS on its list of projects to undertake, but we were not in a position to pursue it,” he said.

‘There were higher priorities’

Michael Kozart, at that time the county’s top staff psychiatrist, was appointed interim division director in March 2018, replacing Kennedy.

Now chief staff psychiatrist with West County Health Centers, Kozart led the division until he left the county in November, shortly before Carter was brought on as division chief.

The health services department in general, and the behavioral health division itself, were in some disarray at the time, Kozart said, and multiple factors conspired to prevent the county from moving forward with the DMC-ODS program while he was interim division head.

Technical issues with inadequate electronic records systems — critical to distinguishing between the different types of medical services being delivered, keeping track of who received what care, ensuring patient privacy and billing for reimbursements — were one obstacle, Kozart said. Turnover among leadership and staff was another. The division’s finances also were a factor, he said.

“It was a really hard time for everything in the department. There was so little organization,” he said. “It was really sad that we didn’t have the opportunity to implement a broader array of clinical programs across the board and Drug Medi-Cal was only one among a number of programs that I wish we had been able to implement.”

He added: “It’s all relative to commitment, in terms of pushing to have the right people in the right positions. I think there were so many challenges with keeping the division afloat that there were higher priorities.”

Asked whether Sonoma County, despite the challenges of that time could have managed to successfully implement the program if it had prioritized doing so, Kozart said: “Is there any reason why Sonoma County can’t rise to the highest levels of excellence in how we care for our community?”

Other factors aside, he said, “Ultimately, all major decisions for programs in the behavioral division were subject to review and approval or disapproval by the health department director.”

‘A slam dunk’

In 2015, Derrick West rejoined the county as a fiscal consultant on the DMC-ODS application. He had been interim chief of the Department of Health Services’ substance use disorder services section between 2011 and 2013.

In an interview, West acknowledged the county’s then-concerns about standing up the program during a time of budget deficits.

But, he noted, those concerns were addressed in the 2017 DMC-ODS “fiscal plan” he helped prepare (and that The Press Democrat obtained from the county through a public records act request) and that satisfied the state and federal governments, both of which approved it. The plan outlined how anticipated DMC-ODS reimbursements, based on historical usage of services, and county and state funds already allocated to substance use treatment, would cover the program’s costs, including initial staffing.

“The state approved (the plan), and that was a very large hurdle,” West said. “And the feds approved it, and that was a very large hurdle. All that was left was the county approval.”

At that point, West said, he left the consulting job for full retirement because “it was a slam dunk. ‘They're going to go to the county and say there are millions of dollars headed your way. There's a contract prepared that's already been sent to us. Go to the board, get approval and sign it, and we're on our way.’”

In 2018 and again in 2019, West wrote to Zane with his concerns, cc’ing the other four supervisors.

He noted the state and federal approvals of the plan and wrote: “DMC-ODS is worth millions of dollars. Many other California counties have already seized this opportunity. Sonoma should follow suit. I cannot encourage you enough to seriously advocate for the immediate implementation of DMC-ODS.”

Zane said she “confronted” Robinson about the issue based on West’s letter, but said she couldn’t remember much else about the conversation, except that “I wasn’t happy about it” and nothing came of it.

West, who has since moved from Sonoma County, said the missed opportunity still pains him.

"When I found out that the county turned it down, I was heartbroken and flabbergasted,” he said. “I still can’t believe we didn’t pull the trigger.”

In January, the health services department asked the Board of Supervisors to allocate just over $1 million in state and “anticipated” federal funds to pay for startup costs for eight new employees to staff the DMC-ODS program. The board approved the request. (The approved 2017 fiscal plan outlined local spending of about $1 million on 15.5 new full time staffers.)

“This is really exciting. I'm glad that we're able to be able to do this. This is something that we're all really committed to as a county,” Struzzo told The Press Democrat. “I mean, this is happening and that's what's really exciting. And I’m just looking forward to the future and where we're going with it.“

When it comes to addressing substance use disorders, Hopkins said, “We need to pursue every possible avenue of funding that can help us address this crisis in our communities. And if we didn't, you know, we need to get started now.”

“It's heartbreaking,” she said, “to think that we left stones unturned when there are people suffering in the community.”

You can reach Staff Writer Jeremy Hay at 707-387-2960 or jeremy.hay@pressdemocrat.com. On X (Twitter) @jeremyhay