Tania Clavell is the stuff of welfare reformers’ nightmares. Two months ago, tired of cycling between high, drunk and sober, the 25-year-old single mother enrolled herself in an outpatient drug treatment program with the help of Medicaid. Though she’s relapsed into cocaine and marijuana three times since then, Clavell is optimistic. “I take care of my kids as well as the next person,” she says. “I just have an addiction problem, which I’m seeking help for right now.”
Clinicians and drug policy experts say that for addicts trying to recover, relapses are common. “It is not unusual for there to be an episode of relapse when someone’s working on their recovery,” says John Coppola, executive director of the New York Association of Alcoholism and Substance Abuse Providers. “It’s part of the recovery process.”
But the city’s Human Resources Administration doesn’t agree. This March, it informed the private agencies that provide substance abuse treatment to people on welfare that they will no longer receive referrals of new clients unless they sign an agreement to report welfare recipients’ treatment progress to the city once a week. And those patients must clean up in just 31 days.
After that, a failed drug test will lose them welfare benefits and access to drug treatment. The first strike gets them suspended for 45 days; subsequent violations lose them benefits for 90 and then 180 days. And under federal law, substance abusers lose their Medicaid along with their welfare checks. About 10 percent of city adults on public assistance participate in a drug program, according to HRA.
Welfare advocates predict the crackdown will have a swift and unmistakable impact. “I think we’ll see more and more people losing their benefits as a result of this,” says Corinne Carey, director of the Harm Reduction Law Project at the Urban Justice Center.
In effect, HRA is mandating total abstinence, a requirement that treatment professionals say contradicts good clinical practice. “There’s no one-size-fits-all solution for treatment, so an abstinence-only model is really not preferable at all,” says Sharda Sekaran, associate director of public policy and community outreach at the Lindesmith Center, a New York-based research group. Quitting cold turkey works for some people but not for others, and in tough cases forced abstinence can make recovery more elusive than ever.
A 1999 report from the National Institute on Drug Abuse emphasizes that drug treatment is an individualized process, which for most recovering addicts takes 90 days before their condition can be stabilized. The best response to a relapse, say experts, is accepting that it happened and addressing the problems that led to it. “As a clinician, I tell my clients, ‘You can make two mistakes, and the first is relapsing,'” says Tony Ortiz of El Puente, a drug treatment center in the Bronx. “The second is, you don’t come back.”
HRA isn’t just breaking all the clinical rules. It’s also flouting everything from state law to medical business practices to do it. The state Office of Alcoholism and Substance Abuse Services, which creates the standards for New York’s substance abuse treatment programs, says the city cannot dictate how abusers are treated. “HRA does not have the legal authority to mandate clinical standards,” says agency spokesperson Gwenn Lee. The state does not recommend timetables for recovery from substance abuse, on the understanding that everyone progresses at a different rate. And the state recommends keeping clients in treatment until they have recovered.
The welfare agency’s intervention in clinical decisions is unheard of even in the micro-regulated world of managed care. “They have insinuated themselves more into the treatment process than many managed care companies do,” says Anita Marton, a senior attorney at the Legal Action Center, which advocates for drug users. HMOs, she observes, “don’t, on a weekly basis, check in and look for intervention. They cede to the professionals their area of expertise, which is not something that HRA is willing to do.”
The city is also forcing the agencies to play informer-to report to HRA on the progress of any clients who, like Clavell, voluntarily check themselves into treatment and use Medicaid to pay for it. HRA will then consult its own records to see if any of those clients are also receiving welfare, and hold them to the same tough timetables as the clients the agency refers into treatment (typically only obvious hardcore users or clients who disclose their own drug use).
The city’s treatment providers are resisting the new directives. In March, Coppola advised his member agencies to hold off on signing the agreement until HRA can assure them that they won’t have to divert staff from other programs to handle the new reporting requirements. A survey by his group found that clinicians at its member agencies already spend 55 percent of their time on administrative work. “One of our real concerns is the fact that this is going to take good clinical time away from clients,” says Kathy Riddle, who runs an outpatient drug treatment center.
Some clinics have complied voluntarily with the treatment rules since they were first recommended in mid-1999, and Carey’s clients have already felt the heat, including a recovering heroin addict who now faces losing Medicaid. Confirms Clavell, “I know a lot of people getting their case closed because they’re not getting clean urine tests.”
But mandatory abstinence is facing a fight. Coppola’s group, as well as the Legal Action Center and Urban Justice Center, say they are exploring their legal options. At press time, HRA was in negotiations with the state substance abuse treatment agency; says Lee, “We’re working on it.”
Tracie McMillan is a Brooklyn-based freelance writer.