Don't let coverage losses undo San Diego's overdose win

In crisis now? Call or text 988, or the Access & Crisis Line: (888) 724-7240 — regardless of insurance status.

San Diego County is in the middle of two curves moving in opposite directions, and the county's own publications document both.

The first curve is the one worth celebrating: overdose deaths down 21% in 2024, down again in preliminary 2025 data, zero deaths under 18 for the first time in years data page 9. That decline was not weather. It was purchased — naloxone at scale, peer responders in emergency rooms, paramedics starting treatment in the field — largely with settlement dollars the county spent faster and more completely than almost any county in California data page 7.

The second curve: Medi-Cal enrollment fell from 854,006 to 785,814 in roughly six months — about 97,000 fewer covered San Diegans than a year ago, with UC Berkeley's county model projecting losses reaching 210,000 by 2028 as H.R.1's provisions phase in data page 6.

These curves are on a collision course. Medi-Cal is the payer behind the treatment system that the overdose response hands people to — and behavioral health patients are uniquely exposed to exactly the way coverage is actually lost: not by ineligibility, but by paperwork. Renewal packets do not reliably reach people who are unhoused (roughly 30% of 2024's overdose deaths data page 9), in live-in treatment, or in crisis. And the populations the overdose decline reached last — stimulant users with no naloxone equivalent, unsheltered residents, the neighborhoods dying at four times the county rate data page 8, data page 9 — are the same populations most likely to churn off coverage silently. See San Diego housing support during treatment for what exists on the housing side.

A person who loses Medi-Cal does not stop needing care. They re-enter through the most expensive door the county operates, uninsured — and the county, not the state or federal government, absorbs the difference.

What we're asking for

1. Treat behavioral health clients as a protected renewal cohort. Direct HHSA to match the BHS client roster against pending Medi-Cal renewals monthly, and route flagged cases to in-person renewal assistance — in clinics, at CSU discharge, and via MCRT peer follow-up. The county already touches these clients; use the touch.
2. Operationalize the H.R.1 behavioral health exemptions. People with qualifying SMI and SUD conditions can be exempt from community-engagement requirements — but only if documented. Fund BHS providers to complete exemption documentation as a standard part of treatment, before the requirements phase in, not after disenrollments hit.
3. Report the collision publicly. Add two lines to the county's monthly eligibility report: Medi-Cal loss counts among active BHS clients, and uninsured presentations at CSUs and county-contracted EDs. If the curves cross, San Diego should see it happening in its own data, not in next year's autopsy of it.
4. Defend the funding that bought the decline — settlement-funded harm reduction and treatment capacity data page 7 becomes more load-bearing, not less, as coverage shrinks. Hold it harmless in FY 27-28 budget deliberations.

The county spent four years and tens of millions of dollars bending the overdose curve. It should not spend the next two watching an eligibility system quietly unbend it.