Rural Issues in Alcohol and Other Drug Abuse Treatment

Rural Issues in Alcohol and Other Drug Abuse Treatment
Technical Assistance Publication (TAP) Series 10

Issues in Providing Alcohol and Drug Abuse Services in Rural/Frontier Counties of California

Kenneth R. Fleming Director
Colusa County Department of Substance Abuse Services Counseling Center
Colusa, California

During the Senate confirmation hearings for Donna Shalala, Secretary of Health and Human Services, an interesting discussion occurred between Secretary Shalala and Senator Baucus of Montana. This discussion alluded to a problem that underlies many of the issues confronting California's rural/frontier counties in providing drug and alcohol services to their constituents. Senator Baucus quite ably described the problem rural States face in providing health services under Federal regulations that do not differentiate between urban and rural States' health care delivery systems.

In response, Secretary Shalala acknowledged these problems and said she intended to avoid health regulations based on the premise that "one size fits all." Senator Baucus replied that there are many other "sizes" reflected in health problems across the United States and that no size should be overlooked.

Purpose

This paper addresses the issues encountered by one size of the alcohol and drug service delivery

system—the organizations that provide alcohol and drug abuse services in rural/frontier counties of urban States. The problems and issues faced by service delivery organizations of this size are often overlooked by decisionmakers at the Federal, State, and urban county levels.

This paper describes the 19 counties in California that have the smallest populations. Each receives a minimum allocation of State and Federal dollars for alcohol and drug services. Key issues affecting these counties are delineated, and the counties' differences from and similarities to rural States are noted.

The issues discussed are the definition of "rural," leadership problems, and funding concerns. These issues do not address all of the problems facing rural/frontier counties in California, but were selected for discussion because of their resistance to attempted solutions over time. For example, the funding criteria for Federal grants were identified as a barrier to obtaining funding in California's rural/frontier counties as early as 1976 (California Department of Health Services). Seventeen years later, the Federal funding criteria still make it difficult for California's rural/frontier counties to access Federal grant funds.

Overview of the California State Alcohol and Drug Delivery System

In the State of California, virtually all publicly funded alcohol and drug treatment, recovery, and prevention programs are planned, organized, and implemented at the county level. State law mandates that each of California's 58 counties appoint an Alcohol and Drug Program Administrator. Usually one person is appointed by the County Board of Supervisors to administer both the alcohol and drug programs. However, some counties (particularly urban counties) appoint separate administrators for each program. The county administrators have the following responsibilities:

Management of the county level process for program planning and priority setting
Administration of all Federal, State, and local public funds for alcohol and drug program services
Consultation with the California Department of Alcohol and Drug Programs regarding statewide program and fiscal policy, program regulations, and legislation

In the early 1970s, the California County Alcohol and Drug Administrators organized two associations to establish statewide forums that could discuss alcohol and drug problems and provide a single point of consultation for the California Department of Alcohol and Drug Programs. The California Association of County Drug Program Administrators was formed in 1973; 18 months later, the County Alcohol Program Administrators Association of California came into existence. The associations are currently holding joint meetings to explore merging into a single association.

Before they established these joint meetings, each association met quarterly. Each had a small and rural counties committee, the membership of which was loosely defined. California legislation provides for separate alcohol and drug services and defines small or rural counties differently for each. For allocating alcohol services, counties with total populations below 200,000 are considered small or rural; regarding drug services, counties with populations below 125,000 are considered small or rural.

These legal definitions continue to be reviewed by the associations and the Single State Agency (SSA). Moreover, in the past year, the associations have identified 19 counties with the lowest levels of funding as Minimum Base Allocation (MBA) counties. Consequently, their small and rural counties committees have been merged and renamed as the Minimum Base Allocation Committee, which serves both associations.

The MBA Committee is the culmination of many years of discussion regarding the definition of rural/frontier counties in California. This leads to the first issue to be addressed in this paper.

Defining "Rurality"

In 1976, small and rural counties in California began lobbying the California Department of Alcohol and Drug Programs to conduct a needs assessment of drug abuse problems in their areas. Originally, the 26 smallest counties were to be included in the Rural Drug Needs Assessment Project (RDNAP). However, at the insistence of urban counties with rural areas, a total of 49 out of California's 58 counties were included. This required that the contractor, California State University—Chico, devise a strategy by which counties could be clustered together based upon varying degrees of "rurality" (California State University— Chico, 1980).

RDNAP recognized that counties could differ significantly despite a shared rural designation. For example, Alpine County, with a population of 1,113, and San Bernardino County, with a population of 1,471,300 (90 percent of which is clustered on 10 percent of the county land mass), are both legally defined as "rural" counties, but they differ greatly in geography, demographic characteristics, and culture. Therefore, RDNAP developed the concept of "rurality," based on a county's population size, population density, percentage of population that is rural, total area, and number of housing units.

Differences by "Rurality"
This concept enabled the project to identify each county in California as "very rural," "rural," "urban/rural," or "urban" and to compare indicator data and planning needs on the basis of rurality. Indicator data from both primary and secondary sources

were found to differ significantly by this rurality, as did characteristics of program staff, demographics of clients in treatment, training needs, unmet needs, and fiscal resources. All the counties identified by RDNAP as very rural, along with the five smallest counties by total population in the rural category, currently make up the 19 Minimum Base Allocation (MBA) counties mentioned previously.

California's current allocation formula is based on a policy put forth by the counties and accepted by the SSA in the 1970s. This policy ensures that a minimum of "core" alcohol and drug services is available to all persons residing in California, regardless of the size of the county in which they live. The core services were originally established as prevention and outpatient services staffed by no more than 1.5 full-time employee positions: a half-time administrator and a clerical position. The number of staff has increased over the years as additional funding has become available in the State, but the definition of core services has only recently been reexamined. The MBA counties and the SSA are currently reviewing a study (completed in 1992) that attempts to redefine core services, based on the actual cost of services.

Definition of MBA Counties
The MBA counties are defined using only the fiscal allocation they currently receive. Consequently, four counties that meet the Federal definition of rural are not MBA counties because their populations are large enough to warrant a greater allocation than the current allocation formula gives to MBA counties. Furthermore, one mountain county (population 30,039) technically defined as urban is included as an MBA

county because its residents' location on a relatively small land mass distorts the population density. With the exception of this county, the MBA counties meet the Federal definition of rural (fewer than 50 persons per square mile), with population densities ranging from 1.51 persons in Alpine County to 50.69 persons in Amador County. The population density for all 19 counties is 9.33 persons, which approaches the Federal definition of a frontier county (fewer than 6 persons per square mile). In fact, if the 5 most populated counties were removed, the remaining 14 counties would have a population density of 5.86 persons. The population density of California counties, and specifically the MBA counties, can be seen in figure 1.

Figure 1
Population Density of the Base Allocation Counties

County	Population	Square Miles	Population Density
Alpine Amador Calaveras Colusa Del Norte Glenn Inyo Lake Lassen Mariposa Modoc Mono Plumas San Benito Sierra Siskiyou Tehama Trinity Tuolumne	1,113 30,039 31,998 16,275 23,460 24,798 18,281 50,631 27,598 14,302 9,678 9,956 19,739 36,697 3,318 43,531 49,625 13,063 48,456	727 601 1,036 1,156 1,003 1,319 10,079 1,327 4,690 1,461 4,340 3,103 2,618 1,397 959 6,318 2,976 3,223 2,293	1.54 49.98 30.89 14.08 23.39 18.80 1.81 38.15 5.88 9.79 2.23 3.21 7.54 26.27 3.46 6.89 16.68 4.05 21.13
TOTALS	472,558	50,626	9.33

The 19 MBA counties have a total population of 472,558 persons spread over a total of 50,626 square miles. This is a larger population than resides in the State of Wyoming and is not much smaller than the States of North and South Dakota.

There are several differences, however, between California's MBA counties and most rural States. These differences are

The MBA counties are not contiguous but are spread across nearly the entire State.
The largest city in the MBA counties has a population of fewer than 15,000 persons.
There are no 4-year universities in any of the MBA counties.
Most of the MBA counties are based upon single-season industries, such as tourism, agriculture, ranching, and logging, which results in high unemployment rates, large numbers of welfare recipients, and small tax bases.
County Boards of Supervisors in the MBA counties are required to implement programs mandated by the State legislature and designed to ameliorate problems most often experienced in urban centers, regardless of local needs and available funding.

Problems resulting from geographic isolation, lack of structural resources, and a rural culture that tends to support individual behaviors, including chronic alcohol use, has made it very difficult for drug and alcohol services to develop in California's rural/frontier counties. These problems are compounded by the lack of a consistent and realistic definition of rural/frontier counties upon which the necessary research and policy studies can be based.

Leadership Issues

California's inability to clearly define rural/frontier counties and to expand the limited resources available to these counties has resulted in a lack of consistent leadership for the MBA counties. Despite the findings of the RDANAP reported in 1980, it was only in the past year that California's rural/frontier counties were able to clearly identify the membership of what is now the MBA Committee.

Furthermore, California's SSA has not identified a specific unit or staff person to support the MBA counties consistently. Frequently, State analysts assigned to the individual MBA counties are reassigned after short periods of time. This has resulted in MBA counties' having to continuously train new State analysts in their unique problems and needs.

The inability of MBA counties to consistently access assistance from California's university system has made it virtually impossible for any of the MBA counties to successfully compete for grant dollars from Federal agencies. Without the system's resources, the counties fail to develop the acceptable evaluation strategies required of all Federal grant programs. Thus, California's rural/frontier counties are left dependent upon minimum allocations of State and Federal dollars distributed by the SSA.

Whereas some of California's urban counties may have millions of additional treatment dollars as a result of direct Federal grants that supplement their allocations from the SSA, none of the MBA counties has successfully accessed direct Federal dollars. In fact, of the 22 direct Federal grants to "rural programs" in California, none are in the 19 MBA counties. As rural States are able to access support from their State universities, so are California's urban counties with rural areas. Consequently, a person living in a rural area of San Bernardino County is much more likely to be able to access a full range of drug and alcohol treatment services than are the nearly half-million persons living in the 19 MBA counties.

As described in the California Rural Needs Assessment Project and more recently in a study by the American Institute for Research (1992), the 19 MBA counties are most likely to have small staffs (averaging fewer than 6 counseling and prevention staff persons), with the program director usually providing both management and clinical services. These clinic directors are most often appointed because of their clinical skills rather than their extensive management backgrounds.

The isolation of MBA counties, their lack of resources, and the clinical responsibilities of their directors make it difficult for consistent leadership to come from the MBA counties themselves. This lack of consistent leadership, combined with the benign neglect of Federal and State decision makers and California's public institutions, leaves the MBA counties without the leadership necessary to adequately address their alcohol and drug program needs. Consequently, most of the twelve drug abuse treatment problems identified in rural counties in the 1980 RDNAP report continue to be problems 13 years later (see figure 2).

Figure 2
Rural Drug Needs Assessment Project, 1980

Problems in Treating Drug Abuse

At the time of the project, many counties allocated less than one full-time position to drug abuse treatment. This results in a lack of personnel and skills to plan and provide comprehensive drug abuse treatment programs. Further, there is little opportunity to coordinate existing resources for these purposes.
Rural areas lack the training opportunities that could improve the effectiveness of their drug treatment staffs. Too many training programs are geared for urban populations and problems and are not suitable for rural personnel.
The shortage of personnel in all human service agencies, as well as their direct-service focus, inhibits county services from coordinating their efforts. Criminal justice personnel, for example, may not be aware of referral options for drug abuse treatment.
Advisors and information provided by the State have traditionally not been requested by or available to small counties. (This situation is changing, however.)
Local funds for drug abuse treatment and prevention are limited. Rural counties are unable to finance drug abuse treatment and prevention efforts, especially when the counties depend on a single industry such as logging or tourism, and when their seasonal unemployment rates are high. Rural counties also include large numbers of people who have incomes below the Federal poverty level.
Many rural counties are conservative; they hesitate to use Federal and State money for local programs, and they channel local money into public works programs rather than social service programs.
Complex contracting processes often discourage rural counties from applying for State or Federal funds available for drug abuse treatment and prevention activities.
Many rural counties assign a low priority to drug abuse treatment programs, which produces a correspondingly low level of service. The image of a drug user remains that of the Haight Ashbury hippie from the 1960s; populations that do not fit this description are simply not viewed as having drug problems. Thus, there is an inability as well as an unwillingness in rural areas to recognize the problem of drug abuse.
Rural drug abuse treatment programs are poorly coordinated as a result of distances, weather, shortage of personnel, and poor communication.
"Turfdom" politics at the local level and county-by-county regulations at the State level often discourage rural counties from coordinating regional efforts. (This is furthered by the county-matched funding requirement of the Short-Doyle Plan, which inhibits regional planning efforts. This requirement has been temporarily rescinded, however.)
The state of the art in drug abuse treatment is oriented toward urban needs. Treatment experts are not entering rural areas; rural drug abuse is less clearly defined, and rural treatment personnel frequently distrust urban resources.
Rural areas offer limited treatment options for drug abusers. The mental health-medical model is usually the only model available, and it may not be the most effective for many drug abusers.

Funding Issues for MBA Counties

California's MBA counties continue to struggle to provide what most urban counties and even rural States consider to be basic service delivery systems. Most of the MBA counties were very slow in developing services for alcohol and drug abuse and currently lag behind in the development of specific services, such as perinatal programs for pregnant and parenting women. This is largely the result of a rural culture that is reluctant to accept Federal—or even State—mandates, and which looks to the individual to "solve his or her own problems." The boards of supervisors in several of the MBA counties have even prevented their program administrators from accepting the perinatal allocations available to them from the California Department of Alcohol and Drug Programs. In addition, the counties' inability to advocate or compete for funds has left them in the unenviable position of having to implement Federal and State priorities at the expense of basic services.

This situation will be exacerbated by the Federal reauthorization legislation, which requires nearly half of the Federal dollars to be spent on specific populations. Also, the HIV and tuberculosis testing requirements will place a disproportionate burden on MBA counties, which often do not have hospitals within their counties and must depend on the overburdened Public Health clinics, which are now losing funding as a result of California's budget crisis. It is the view of most MBA county administrators that implementing the Federal guidelines will decrease the services available as the cost of these services rises dramatically.

The problems inherent in categorical funding for MBA counties have been made difficult to respond to by a decision to "proportionalize" the amount of Federal and State money each county receives annually. As increased Federal funding came to California, administrators in some large counties became concerned that they were receiving smaller proportions of State general fund dollars and that this would leave their programs vulnerable if there were future cutbacks in Federal funding. The SSA decided to make the proportion of Federal and State dollars the same for all counties over a 3-year period.

Before proportionalization, the typical MBA county was receiving approximately 75 percent of its budget from the State general fund and the remainder from the Federal block grant. Administrators in MBA counties were able to spend State general fund dollars on any service approved in the county plan as submitted annually to the SSA. This allowed MBA counties to support prevention and intervention programs, which were most often provided at local schools. This collaboration between MBA county alcohol and drug programs and county schools frequently provided the political support necessary to convince local decisionmakers to allow the development of alcohol and drug prevention and treatment services.

However, before the counties could develop a full range of services, the availability of State general fund dollars began to shrink and Federal dollars, which mandated spending in specific areas, replaced them. Because the total budget of an MBA county is relatively small, the discretionary dollars (both State and Federal) that were available had to be spent on categorical services to meet the mandates. For example, to meet the Federal Women's Set-Aside requirement, it was usually necessary to supplement the allocation of $5,607 by three or four times the allocated amount to be able to provide any service at all. The dollars deducted from the MBA counties State discretionary funds were transferred to urban counties, which were able to use them to meet the categorical funding requirements.

The ratio of State to Federal funds for MBA counties has now inverted, with approximately 25 percent of county budgets coming from the State general fund and 75 percent from the Federal block grant. This reduction in flexibility between funding streams has resulted in MBA counties spending virtually all of their allocation on mandated services, which often do not meet the priorities established by the local planning process. Because these priorities are not addressed, the administrators in the MBA counties sometimes find they do not have the support needed locally to implement the mandated programs (as is the case with perinatal programs).

The MBA counties lack access not only to major ancillary resources, such as hospitals, universities, and other public sector institutions, but also to ancillary treatment resources common in urban counties, such as private, nonprofit alcohol and drug program providers and private practice psychologists, social workers, and counselors. Well funded service organizations, private employers, and foundations that provide funding to enhance urban programs are also unavailable in the MBA counties. This situation is best illustrated by the following example.

Friday Night Live, a high school-based alcohol- and drug-free recreation program that has been actively supported by the California Department of Alcohol and Drug Services, is funded in urban counties with donations from fast-food chains, local service organizations, and foundations. Because these resources are unavailable in most MBA counties, their Friday Night Live chapters are funded only with the $3,000 made available by the California Department of Alcohol and Drug Programs. As a result, some urban programs spend in excess of $300,000 to support Friday Night Live activities, while MBA counties must rely on the minimal allocation available from the State.

Summary

More people live in California's MBA counties than in some rural States. How ever, because of a lack of personnel and resources, scattered populations, great geographic distances, and a lack of infrastructure resources, the MBA counties continue to struggle to provide basic alcohol and drug services. They have been unable to compete with their colleagues in urban counties for additional funding, either through the SSA or directly from Federal sources.

MBA administrators supervise clinical staff, provide direct client services, and handle the voluminous mandatory paperwork. They often work without computers or use them only for straightforward tasks such as word processing, because no computer sales and programming services are available to them in their counties. If nothing else, these administrators are realists who accept the limitations of working in rural areas. They recognize the political obstacles they must face daily and do not delude themselves about the amount of influence they have with Federal, State, and university decision makers. Consequently, MBA county administrators have joined together to exert moral pressure (in lieu of political clout) as best they can. Furthermore, they recognize the necessity for structural changes at the Federal and State levels if the people needing alcohol and drug services in their counties are to be adequately served.

Recommendations for Improving Alcohol and Drug Services in Rural/Frontier Counties in Urban States

The California Rural Needs Assessment Project completed six regional plans in 1979 as part of its activities. Counties of varying "rurality" were clustered into contiguous regions. All six plans identified the need for technical support, either from the Single State Agency or in the form of regional centers. Rural/frontier counties needed help in the areas of planning, grant writing, staff recruitment and training, program evaluation, and the development and maintenance of management information systems.

A group of MBA county administrators spent 2 days together in 1989 identifying their counties' problems and needs, including the need for ongoing regionalized technical assistance. A recent funding study of the counties by the American Institutes for Research also identified regional technical assistance pools as being necessary to remedy the lack of infrastructure in MBA counties. Thus, I would make the following recommendations.

First, the States, Federal agencies, or both should provide rural/ frontier counties in urban States with technical assistance to enable them to plan programs, develop grants, and evaluate the programs' effectiveness. This should be done through regional centers controlled by the counties.

Second, Federal agencies must require urban States to define their rural/frontier areas and to assess currently available resources in and unmet service needs of these areas in the annual State plan. This recommendation was first made in a report of the Secretary of Health, Education, and Welfare (1979). The States' failure over the past 12 years to implement this recommendation in any meaningful way leads to my next recommendation.

Third, the Substance Abuse and Mental Health Services Administration should name a rural advocate at the national executive level who can lobby for the needs of rural States and rural/frontier counties in urban States. This recommendation can also be applied at the State level in large urban States such as California, where the SSA lacks an advocate for rural areas. Such an advocate might also sensitize and train State employees responsible for working with the rural/frontier counties.

References

American Institutes of Research. Final Report. Rural Counties Comprehensive Services Funding Project, 1992.

California Department of Health Services, Division. of Substance Abuse Services. Discussion Paper. Rural Counties Overview, 1976.

California State University—Chico. Report. A Summary of the Rural Drug Needs Assessment Project. The Human Services Center, 1980.

Secretary of Health, Education, and Welfare. Report. Drug Abuse in Rural Communities, January 3, 1979.

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