The question came out of the blue, or so it seemed to Crossing Healthcare CEO Tanya Andricks: If you had $30 million to design an addiction treatment facility, how would you do it?

The interim sheriff of Macon County, Illinois, posed the question in 2018 as he and Andricks discussed the community’s needs. When she responded that she’d have to do some research, she was told not to take too long because the offer wouldn’t be there forever.

“I thought: ‘Oh my God, he’s serious,’” Andricks said.

That sheriff was Howard Buffett, the philanthropist son of billionaire investor Warren Buffett. The younger Buffett ended up giving Crossing about $30 million from his charitable foundation to build an addiction treatment center in Decatur, a city with a population of just over 69,000 in the heart of Macon County.

There was a caveat, though. The donation to Crossing was a one-time gift to pay only for the buildings. It was up to Andricks and her team to find money to run the programs. And that has proven difficult.

The COVID-19 pandemic upended everything mere months after the facilities opened in October 2019. An audited financial statement said the inpatient recovery center had lost $2.5 million by June 2021, and management worried about its ability to continue operating. Even so, the center remained open while other addiction treatment facilities around the country shuttered.

Now communities nationwide are preparing for an unprecedented windfall of their own for addiction treatment from a nearly $26 billion national opioid settlement and a more than $300 million expansion of a federal pilot program for mental health. The experience at Crossing offers them a model but also a warning: It will take more than a single shot of money to build a treatment program that can last.

Drug addiction wasn’t on Howard Buffett’s radar, he said, until he joined the Macon County sheriff’s office as an auxiliary deputy in 2012. While the county has had some treatment resources, like a behavioral health center, it has one of the state’s higher death rates from opioid overdoses.

Buffett moved to the area in 1992 to work for food-processing giant Archer Daniels Midland. He runs a farm nearby and his Decatur-based foundation donates hundreds of millions of dollars for initiatives ranging from helping people kidnapped by Joseph Kony’s Lord’s Resistance Army in central Africa to revitalizing the cacao industry in El Salvador.

Soon after Buffett was appointed interim sheriff in 2017, he toured Crossing to learn more about local social services. The health center offers primary care including mental health for all ages, and sees roughly 17,500 patients a year. Most Crossing patients are on Medicaid, the public health insurance for people with low incomes.

“He was impressed with what we were able to provide patients,” Andricks recalled. “I don’t think he expected the scope and size of what we do.”

Addiction treatment, though, is notoriously difficult. Evidence supports treating addiction like a chronic illness, meaning even after difficult short-term behavior changes, it requires a lifetime of management. Research suggests relapse rates can be more than 85% in the first year of recovery. So any new treatment program is likely to face headwinds.

Buffett didn’t set Crossing up for failure. In fact, he has helped fund other aspects of the organization’s work. Part of the idea behind paying for the addiction treatment buildings but not the operations, Buffett said, is to keep his foundation “creative.” If it spends all its money on the same programming every year, that means less is available to fund other work around the globe. Buffett said it’s also about sustainability.

“If Tanya can show ‘with this investment I made this work,’” Buffett said, “then other people should be making that investment.”

Crossing’s inpatient recovery center holds eight beds for medication-assisted detox, 48 beds for rehabilitation, and a cafeteria where meals are cooked with input from dietitians working with patients. An outpatient treatment center also has classrooms for continuing education, a gym with a small bowling alley, and a movie theater. Buffett insisted on the last two amenities. (“People have to feel good about getting better,” he said.)

A separate building holds 64 beds of transitional housing and just across the street are 20 rent-controlled apartments. Buffett spent an additional $25 million on buildings at that campus for other organizations focused on housing, workforce development, and education, among other things.

“There’s a lot to like in this program,” said Dr. Bradley Stein, director of Rand Corporation’s Opioid Policy and Tools Information Center.

As positives, Stein pointed specifically to the spectrum of care offered to patients as they progress in their recovery; the use of medication-assisted treatment to help stave off physical cravings for opioids; the connection to the health center; and even the involvement of law enforcement.

Laura Cogan, a 36-year-old mother who has struggled with addiction since she was 14, is one of the patients working their way through the system.

Cogan said she was the first patient in the doors when the recovery center opened. Less than 24 hours later, she was also the first patient to walk out.

The biggest challenge with Cogan’s previous attempts at recovery, she said, was never being sure about her next steps: What was she supposed to do after getting out of detox and residential treatment?

Crossing’s approach was designed to address that by providing transitional housing, easy access to outpatient services, and educational programming.

On her third attempt, Cogan got a round of applause after completing the first three days in detox. After six days, she joined residential treatment. After a month, she moved over to transitional housing, began outpatient treatment, and started offering peer support at Crossing. She tutored other patients, taught a writing class, and helped them get on computers and fill out job applications.

Then the pandemic hit.

Like health centers around the nation, Crossing turned its attention to providing COVID testing and vaccines. Meanwhile, just about every aspect of addiction treatment became more expensive. Crossing halved the number of residential treatment beds so each room would have only one patient and converted the rooms into negative pressure chambers to reduce risk of COVID transmission.

Staffing grew harder amid a nationwide nursing shortage. The number of patients in residential treatment dropped, Andricks said, because few people wanted to live inside a facility and wear masks. It was common to have as few as 10 beds occupied on a given day. The women’s unit was temporarily closed due to lack of demand and staffing constraints.

Cogan said several other transitional housing residents left once the $1,200 pandemic stimulus checks arrived, with some resuming treatment when that money dried up. But Cogan continued. Eventually she moved into Crossing’s rent-controlled apartments, where she has been one of just a few tenants.

Without the federal Paycheck Protection Program’s $1,375,200 forgivable loan in 2020, Andricks said, the outpatient treatment program might have had to close altogether.

But momentum at the recovery center started to change last spring as COVID cases tapered off, Andricks said. Hiring became easier. More patients arrived. In October, the center received a grant to use the apartments for women with a history of substance misuse who are pregnant or who have given birth within the prior year. They’ve placed six women there already, in addition to Cogan. The inpatient recovery center now averages about 27 occupied beds a day, within striking distance of the 30 that Andricks said the inpatient center needs to survive.

Rand’s Stein suggested another measurement of a treatment program’s success: whether people in the community get into treatment when they need it. National “secret shopper” reports have found significant barriers to service, such as long wait times.

Crossing’s program quadrupled the number of residential treatment beds in Macon County, according to Andricks. In the three years since the inpatient recovery center opened, it has had over 1,300 admissions. While most patients haven’t stayed in recovery, staffers have seen a pattern of success with those like Cogan who stay on campus and become involved with recovery offerings — although Andricks estimated that’s fewer than 10% of the patients.

Cogan said she hopes Crossing doesn’t get discouraged. People are going to mess up, she said, but she’s living proof of the impact the recovery center can have.

“I’m one of the lucky ones and I don’t know why,” Cogan said, sitting on a couch in the apartment on Crossing’s campus that she shares with her 12-year-old son since regaining custody of him. “I just know that today I am. And I hope that more people get the opportunity.”

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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