A massive overhaul of the state’s substance abuse treatment system is making it easier for counties to help people struggling with drug and alcohol addiction, a new report by the California HealthCare Foundation has found.

For decades, people enrolled in Medi-Cal—the state’s low-income health insurance program—had difficulty accessing substance abuse treatment. Medi-Cal covered only a small selection of addiction treatment services, and there was no organized system to help them find quality care.

Under the new Drug Medi-Cal Organized Delivery System, participating counties can offer a much broader array of services to people with substance use disorders, coordinate and manage those services, and monitor the quality of care. Counties can also pay providers better rates, encouraging more of them to accept Medi-Cal patients, according to the Aug. 3 report. Medi-Cal covers more than a quarter of the state—about 10.7 million people.

“It’s been an enormous change,” said William Harris, assistant regional manager of Riverside County’s substance abuse treatment program, which was featured in the report. “We’re operating under an entirely new paradigm and are able to expand services and be more inclusive and better meet the needs of the population of our county.” The new program allows Riverside to offer more services and treat more patients than ever before, Harris said.

California is the first state in the nation to implement the delivery system, authorized as a five-year pilot program by the federal Centers for Medicare and Medicaid Services. So far, 19 counties have adopted the program, and another 21 are scheduled to in the coming months. These counties represent 97 percent of the state’s Medi-Cal population. However, 18 counties in northern and eastern California have opted not to implement the changes.

The California Health Care Foundation study focused on four early adopters of the new system: Riverside, Los Angeles, Marin and Santa Clara counties, which launched the program in 2017. Co-author Molly Brassil said the report offered a chance to reflect on the successes and challenges faced by those counties, so that other jurisdictions can learn from them.

“This report sort of tells the story to other counties that, yes, (the implementation) is not without challenges and it isn’t easy, but it’s doable,” she said. “I was taken aback by how positive all the counties were given the tremendous lift it is for all of them.”

Challenges faced by the early adopters include developing the administrative infrastructure for the program and finding enough providers to offer the newly covered services, the report said. Riverside, for example, was surprised by the huge volume of calls it received after launching a hotline to screen people for substance abuse disorders and refer them for treatment. Since February, 2017, they’ve received an average of 4,000 calls a month, requiring the call center to triple its staff, said Harris.

“That was shocking,” he said. “We had no good idea how much the calls would go up.”

Other challenges include ongoing societal stigma and misconceptions about substance use disorder, counties reported. Until now, addiction has typically been viewed as a moral and individual failing. The new system strives to treat substance use disorder like any other medical illness, and not blame patients for their condition. Public attitudes have yet to catch up with this paradigm shift, the study noted.

Over time, Brassil said the goal is for substance abuse screening and treatment to become a mainstream part of health care. State and county officials hope the federal government will agree to continue the program long-term, she said.

“We’ve heard from folks overall that this is the right thing to do,” she said of the new system. “It’s hard, but that doesn’t mean it’s not worth doing.”