City and state governments around the US are facing a fiscal crisis as the coronavirus pandemic has taken away sales tax and other revenues. Because of “balanced budget” laws in many jurisdictions, governments unable to run deficits are being forced to cut spending and lay off public sector workers. Harm reduction services that rely in part on public funding, including syringe exchanges and naloxone distribution, may now be put in danger.
“State budget shortfalls this time around could total more than $500 billion in a single year, and cities and states across the country are sounding the alarm,” wrote Emily Stewart for Vox. Budget troubles vary widely across the country. Maryland and Colorado may each face a nearly $3 billion shortfall. New York may lose $10-15 billion in tax revenues. Ohio is considering cutting 20 percent of its spending, while Nevada may cut as much as 14 percent of spending for the next fiscal year.
The situation gets very grim at the city level. Cities with populations under 500,000—including “small towns” like Oakland and Cleveland—did not receive any economic relief in the last federal coronavirus stimulus bill, the CARES Act. Cities like Cincinnati and Dayton are already furloughing workers, putting them on leave, or not paying them. But even a big city like Los Angeles is considering furloughing 15,000 workers, while Baltimore considers $11 million in budget cuts. The services nationwide that may be impacted by these cuts include paramedics, sanitation, firefighters and police.
Many harm reduction programs throughout the US rely on state and local governments for at least part of their funding.
On May 12, Democratic leadership in the US House of Representative released a new coronavirus stimulus bill. The $3 trillion aid package, dubbed the “Health and Economic Recovery Omnibus Emergency Solutions” or HEROES Act, includes over $1 trillion in assistance to state, city and tribal governments to prevent layoffs. That includes $375 billion for smaller suburban and rural towns left out of the CARES Act.
The bill could receive a vote in the House as soon as May 15, but Republicans have vowed to block it.
Many harm reduction programs throughout the US rely on state and local governments for at least part of their funding. These programs offer life-saving services to people who use drugs, who may not find them anywhere else. These include distributing sterile syringes and other supplies to prevent blood-borne diseases like HIV or hepatitis C; the opioid overdose antidote, naloxone (Narcan); test strips to detect fentanyl in your drugs; safe sex supplies like condoms or lubricant; and even simple things like a place to sit with some coffee and watch TV.
These programs may be run by private non-profit organizations or by local public health departments. Of course, some areas of the US don’t have any publicly funded harm reduction. Programs in these places and others are run by volunteers, and may raise some money or resources through private donations and the occasional government grant. Either way, the fiscal crisis both threatens funding for existing harm reduction and dashes hopes for funding new programs.
In Los Angeles, the fiscal crisis is having different effects on various public health departments. Syringe exchange programs are funded by both the City and County of Los Angeles. Filter reported on the work of the ReFresh Spot in Skid Row, for example, which besides clean syringes and naloxone also provides a mostly homeless clientele with the basis necessity of clean toilets.
In addition, substance use disorder treatment in LA—including with medications like buprenorphine and methadone—is provided by the county through the state’s Drug Medi-Cal program. Those services are available to people eligible for Medi-Cal or My Health LA, both of which are no-cost healthcare programs for low-income residents. Drug Medi-Cal also helps provide naloxone to people at risk of opioid-involved overdose.
This is in a city and county where drug overdose deaths have increased significantly in the last decade, with the rise primarily driven by methamphetamine. Opioid-related hospitalizations and emergencies have also increased significantly in that period. Homelessness has also risen over the past several years—up 12 percent in 2019 to over 59,000 people living on the streets.
Looking at the state level in California, the signs are that spending cuts will hurt harm reduction work. Finance officials announced May 10 that California faces a $54.3 billion budget deficit, and will make significant cuts in the absence of federal assistance. The deficit was partially driven by increased spending on the Medi-Cal program even before the pandemic.
Homeless Healthcare Los Angeles, which also operates the ReFresh Spot, told Filter that its Center for Harm Reduction depends on city and county grants for about a third of its budget. Its total budget is about 80 percent publicly funded, with the remainder coming from private donors and foundations. The nonprofit is not aware of specific funding cuts, but is expecting some to be made.
“I live for crisis—COVID-19 has been an awesome funding strategy for HHCLA,” said Mark Casanova, the agency’s director. “Crisis tends to bring out the good in funders and as a nonprofit you have to be nimble and quick in trying to secure the necessary funds to deal with crisis. We have never solely relied on any public funding for the syringe exchange.” His organization has received a $100,000 grant from healthcare conglomerate Kaiser.
“We expect adjustments to our budget will be necessary in the coming weeks and months.”
Meanwhile, LA County Department of Public Health officials conceded there may be some changes to harm reduction services, though would not get into specifics. “Though Los Angeles County is forecasting a significant budget reduction given the COVID-19 pandemic’s impact on sales tax revenue, we remain committed to our mission of providing substance use disorder prevention, treatment and harm reduction services,” Lello Tesema, of the county’s Substance Abuse Prevention and Control office, told Filter.
“We are evaluating and planning for possible program reductions while maintaining high-quality services that benefit the well-being of Los Angeles County’s 10 million residents,” she continued. “We expect adjustments to our budget will be necessary in the coming weeks and months as the impact of the pandemic evolves, and are prepared to do our part to balance the reality of resources available with the needs of Los Angeles County residents.”
Los Angeles’ AIDS coordinator sounded a slightly more optimistic note, however. The city allocates about $1.2 million through this office for HIV/AIDS prevention. Roughly half of that amount goes towards harm reduction and syringe exchange programs, with the rest going to HIV education and other services.
“My staff and I will need to plan for 26 unpaid furlough days in the next fiscal year.”
“In the current fiscal year, our budget was cut by 3 percent but we were able to absorb the cut through internal savings and programs were not affected,” LA AIDS Coordinator Ricky Rosales told Filter. “The latest iteration of the mayor’s proposed budget does not outline any budget cuts for us in the next fiscal year. The one thing I do know for certain is that my staff and I will need to plan for 26 unpaid furlough days in the next fiscal year.”
It’s too soon, then, to know exactly how the fiscal crisis will affect harm reduction in Los Angeles. Both the AIDS coordinator and the county health departments told Filter that their jurisdictions are actively lobbying the federal government for direct financial support, including for harm reduction work.
In the nation’s largest city, people using drugs face opioid-involved overdose and homelessness crises that both long predated coronavirus. There are over a dozen syringe exchange programs in New York City, which are primarily supported with public funding. The NYC Department of Health and Mental Hygiene told Filter that it will have spent over $70 million, including $32 million in state dollars, by the end of this fiscal year on harm reduction programs.
As in Los Angeles, the department was not specific about the potential impact of any future budget cuts. “The city’s funding priorities are the health and safety of New Yorkers, putting food on everyone’s table and keeping a roof over their head,” said Deputy Press Secretary Stephanie Buhle. “We are constantly in touch with the administration about budget issues given the economic uncertainty and will resolve funding issues through the budget process.” She added that the city is lobbying Congress for direct assistance, including for harm reduction programs.
“They told us that ‘due to economic uncertainty, they recommend we stock up on supplies.’ That’s a sign we won’t be getting as much funding.”
But harm reduction providers told Filter that most are now expecting their funding will be “severely compromised.”
“It’s extremely unclear and I think that’s intentional,” said Arash Diba, harm reduction director for VOCAL-NY. “Your funders never want you to know about cuts until they happen because they want you to keep providing services and keep morale high.”
“We got some emergency funding from the city, but it has to be spent before July 1,” he continued. “They told us that ‘due to economic uncertainty, they recommend we stock up on supplies.’ That’s a sign we won’t be getting as much funding.”
The impact caused by prospective funding cuts will vary between harm reduction providers in different parts of the city and state. VOCAL-NY suggested that regions of upstate New York, where there is already much less harm reduction available, will be affected much worse than New York City.
Asked how providers would adapt to funding cuts, Diba said, “You just have to do more with less.”
Harm reduction work in New York has been under attack since long before coronavirus-fiscal crisis.
Every harm reduction organization has different resources and funding sources. Those that are larger and more established are likely to fare better than smaller and newer organizations, said VOCAL-NY. Some organizations will be better able to fundraise and receive private donations to offset public cuts.
Harm reduction work in New York has been under attack since long before coronavirus-fiscal crisis, explained Jasmine Budnella, VOCAL-NY’s drug policy coordinator.
In early April, New York state lawmakers negotiated the state budget, and in doing so implemented a series of austerity or anti-harm reduction provisions sought by Governor Andrew Cuomo. These included cutting money from the state Medicaid program; banning flavored vapes; repealing cash bail reforms, which will result in more people being jailed; and omitting affordable housing support for over 250,000 homeless New Yorkers.
The state has also previously cut funding for harm reduction programs. In New York, syringe exchanges and similar services called Drug User Health Hubs are funded by the AIDS Institute, a branch of the state Department of Health. Budnella explained that the AIDS Institute budget has been continually cut over the years. Drug User Health Hubs, specifically, each had their budgets cut by $90,000 as of October 2019.
In 2019, Cuomo also cut $62 million in Article 6 public health funds to New York City. This is money given directly to the city to fund various services, including sexual health and HIV/AIDS and viral hepatitis prevention.
What governments choose not to do is as impactful as funding cuts they do impose. As Filter has reported, Governor Cuomo has endangered the lives of people using drugs by stonewalling New York City’s efforts to build safe consumption sites. Although the city’s mayor approved the nascent program two years ago, Cuomo has effectively stopped it from moving forward by mandating that his health department review it first.
Cuomo has also prevented low-income New Yorkers from getting access to life-saving medications like buprenorphine or methadone for opioid use disorder. A bipartisan group of state lawmakers passed a bill in both chambers last year that allowed people on Medicaid to be prescribed these medicines without having to wait for Medicaid to authorize it. But Cuomo waited until New Year’s Day to finally veto the bill, despite the fact it would save an estimated 600 lives and $52 million each year.
Nationwide, harm reduction advocates will have to fight against lawmakers who wish to exploit the crisis to cut healthcare and resources for low-income residents and people using drugs. But if state and local governments want to support harm reduction work but don’t have the funds to do so, there is much else they can do that would still end up saving lives.
“Across the nation, there’s various issues where people can’t expand harm reduction services on very limited budgets,” Budnella said. “There’s underground and not-legal syringe exchanges in places where governments don’t give any funding. But in those places and even here in New York, there’s significant policy changes we’ve been fighting for for years that would save people’s lives in this COVID-19 moment.”
Many of these actions wouldn’t require additional public spending—and some would even save governments money.
These include decriminalizing syringes and increasing access by removing any possession limits, Budnella said. Governments can also decriminalize drugs like buprenorphine, so that people aren’t arrested for buying and selling it on the streets. They can allow these medications to be offered in prisons and jails to people who need them. They can allow providers to create safe consumption sites.
Many of these actions wouldn’t require any additional public spending—and some would even save governments money. The question, then, for state and local governments reeling from a massive fiscal crisis during the pandemic, is if they have the political will to prevent more people who use drugs from dying.