A measure on the upcoming March ballot, Proposition F, is San Francisco’s latest attempt to do something about its drug overdose crisis. A record 806 people died of overdose in the city last year, mainly driven by the opioid fentanyl.
What Prop F can do, however, is highly disputed. Backers and opponents who spoke with The Frisc have widely divergent views of its potential effects; neither side could provide evidence to back themselves up.
Prop F would require recipients of the city’s cash assistance program to submit to drug screening, evaluation, and if deemed necessary, drug treatment, in order to keep receiving payments. Backers including Mayor London Breed, who put Prop. F on the ballot, say it will reduce the number of overdose deaths. Opponents say it would be harmful and contribute to more homelessness.
If the proposition is approved (it requires a simple majority vote), it would apply to adults under the age of 65 with no dependent children who participate in the County Adult Assistance Program, or CAAP.
In addition to an evaluation of employability, which recipients already undergo, those suspected of using illegal drugs would also have to submit to drug screening, evaluation, and treatment for those deemed in need. (The proposition’s text says the screening would be set in motion when “there is a reasonable suspicion that an individual is dependent upon illegal drugs.”)
Those who decline to participate would lose eligibility for cash benefits. The city would grant at least a 30-day grace period to avoid immediate eviction.
[Editor’s note: Feb. 20 is the deadline to register to vote in San Francisco’s March 5 election.]
Breed spokesperson Joe Arellano says Prop F is necessary to help combat the fentanyl crisis. He also calls it a personal matter for the mayor, who lost her sister to addiction. “She really views Prop F as another tool that the city can use to compel people into treatment, so that we can make sure that we’re saving lives and so that families who have lost folks to addiction don’t have to lose anyone else,” said Arellano. “It’s very important that we work to address the situation on our streets, but also do it in a compassionate way that is going to get folks into treatment.”
[Update 2/8/24: After this story’s initial publication, Arellano clarified that the process would not require urine, blood, saliva, or other invasive tests. A CAAP recipient would be evaluated only through visual inspection, oral questionnaires, and written surveys.]
Arellano said there were no studies to back Prop F’s approach or evidence that it would achieve its goals.
The new ordinance, if approved, would allow people to miss three appointments in their treatment regimen before cash payments are revoked, according to Arellano, although there is no mention of this specific rule in the proposition’s text. (It does say that “reasonable participation” is required, but staying sober is not.)
The city controller estimates that the program would cost between $500,000 and $1.4 million annually to administer. These costs could be offset by yearly savings between $100,000 and $2 million “from recipients who are no longer eligible to receive aid,” and that money would go into a fund available to spend on treatment and other services. “It is unknown exactly how many clients would be discontinued under the proposed ordinance,” according to the controller’s report.
Another reason for Prop F is to “discourage people from other cities who come to San Francisco to get financial assistance,” said Trent Rhorer, executive director of SF’s Human Services Agency, which administers the CAAP program.
As of November 2023, there were 5,374 people actively receiving CAAP payments, which accounted for $30.3 million in the fiscal year 2022. Monthly cash payments are based on housing status. About half the people in the program are housed of their own accord and receive $712 a month. The other half are in temporary shelter or housing with the program’s help and receive up to $109 a month. The CAAP program also offers non-cash services, such as help navigating state and federal assistance programs. Prop F would not affect those services.
Contribution tally
So far, supporters of Proposition F have raised $406,500, in large part from four people: tech investor Chris Larsen ($250,000), Yelp CEO Jeremy Stoppelman ($75,000); former Zynga CEO Mark Pincus ($25,000), and entrepreneur Asheesh Birla ($25,000). No contributions have been made in opposition, according to the city’s campaign finance dashboard.
One main opponent, the Coalition on Homelessness, doesn’t have money to donate, according to organizer Javier Bremond. Bremond says Prop F will worsen the housing crisis by cutting people off from their cash assistance and ability to pay rent. “What we should be doing is hiring more clinicians and encouraging people to go into treatment right now and make it easier for people to have treatment access right now, not kicking them off their benefits just to force them into a treatment program,” said Bremond. “It’s like this is a throwback to the ’80s and ’90s during the height of the drug war.”
The city currently has 2,550 beds for drug treatment and other behavioral health patients. A small fraction of them are available at any given time.
One Prop F backer told The Frisc that some people need to be compelled into treatment. “I know what it’s like to be an addict. I know what it’s like to live in the streets, and I know that it takes someone to have enough concern about me to make me do something different,” said Cregg Johnson, co-founder of Positive Directions Equals Changes, a support organization for people with addiction and mental health issues.
Bremond said studies show the Prop F approach would be harmful, a claim echoed by the official opposition argument penned by a nurse and former SF public health commissioner: “Research by public health experts shows indisputable evidence that proposals such as Prop F lead to increased rates of return to substance use, overdose deaths, and suicide.”
When asked to identify the research, Bremond said he would follow up but never did, despite repeated requests. Mission Local spoke last fall to several experts who said Prop F goes against “best practices” that call for voluntary participation in drug treatment, would deprive people of food and rent money, and could result in more crime.
Pro and con agree on this
Supporters and opponents alike agree on at least one issue: San Francisco, already facing 10 percent across-the-board budget cuts to reckon with a $800 million deficit, doesn’t have enough resources to help everyone who wants treatment. The shortage applies to shelter and permanent housing for people sleeping in the streets, as well as to spaces in drug treatment facilities. The city currently has 2,550 “beds” — in-patient spots — for drug treatment and other behavioral health patients. A small fraction of them are available at any given time.
“I think the city will need to expand its treatment capacity,” said District 8 Sup. Rafael Maldelman, who supports Prop F.
Mandelman added that the Human Services Agency “may set up its own additional treatment programs beyond those that the Department of Public Health has going” if Prop F passes. But he acknowledged that officials need to fill in details before the program starts in January 2025. “I think it’s worth trying, and if it doesn’t work then we should stop,” Mandelman said.
If a CAAP recipient wants treatment but is forced to wait because of space limitations, they would continue to receive cash benefits, according to Mandelman. The controller noted that some services, including medication treatment, outpatient treatment, and support groups, should have capacity to absorb CAAP recipients who opt in.
But the city might fall short when it comes to providing beds and rooms for residential treatment, withdrawal management, or live-in “step down” programs. It’s not clear how much the extra capacity would cost, but the controller noted that a 90-day stay in a residential treatment program ranges from $28,000 to $40,000 per person, with insurance reimbursing just over half the cost.