An examination of recovery housing in the U.S. reveals a major gap in effectiveness research and uneven success in overseeing operations at the state level. The Government Accountability Office (GAO), Congress's investigative arm, states in its report on recovery homes that while Florida investigators have made significant inroads in combating abuses in the largely unregulated industry, efforts to clamp down on questionable practices have shown little progress in states such as Texas and Utah.
The GAO report, Substance Use Disorder: Information on Recovery Housing Prevalence, Selected States' Oversight, and Funding, is based on a review of oversight activity in five states: Florida, Massachusetts, Ohio, Texas and Utah. The GAO's findings depict a lack of consistency in the extent to which the states have taken measures to advance standards of sober home operation and to improve quality, as well as how much they have tapped into limited opportunities for funding support at the federal level.
The report adds that while some research has shown promising effects of recovery housing on residents' long-term sobriety, “much of the available research on effectiveness of recovery housing focuses on the [self-funded] Oxford House population, and research on other types of recovery homes is limited.”
It remains to be seen whether the members of Congress who commissioned the report—some of whom have expressed concern over the proliferation of sober homes in their home states—will attempt use the findings to build momentum toward any federal legislation.
“We're not sure what will happen now that it's out,” says Dave Sheridan, president of the National Alliance for Recovery Residences (NARR), which provided significant input during the GAO's research.
Basic data lacking
The report focuses on peer-run recovery housing that does not encompass any clinical services, which generally means that its scope is limited to the level I and II homes in the four-level definition of recovery housing as advanced by NARR.
The GAO points out that overall, no one knows the true prevalence of recovery housing in the U.S., because NARR has formal state affiliates in only just over half of the states, and sober homes are generally protected from local regulation of siting by virtue of the Fair Housing Act. Fifteen NARR affiliates in the states are certifying recovery homes, according to the report, and as of January nearly 2,000 homes across the country had been certified as meeting NARR standards of operation.
In all five states reviewed for the report except Texas, law enforcement investigations of recovery home operators suspected of wrongdoing have taken place. The GAO reported that an official from the Texas Department of Insurance “told us that the department received two fraud reports in 2014 and 2016 related to recovery homes and that the state was unable to sufficiently corroborate the reports to begin investigations.”
On the other end of the spectrum, Florida as of last December had seen more than 40 individuals charged with offenses related mainly to patient brokering schemes, and more than a dozen have been convicted and fined and/or sentenced to time behind bars.
In Ohio, officials with the state's Medicaid fraud unit confirmed to the GAO that a Medicaid provider is under investigation for offenses ranging from paying kickbacks to sober homes in exchange for patient referrals to billing for excessive drug testing. While that investigation is ongoing, state officials told congressional investigators that they do not believe fraud is widespread in Ohio's recovery housing and outpatient treatment community.
The GAO report found that in the areas of oversight and funding support for recovery homes, approaches vary widely from state to state.
Florida and Massachusetts each have established voluntary certification programs for recovery homes, with each incentivizing participation by prohibiting some referrals to recovery homes that are not certified. Florida's regulatory approach is largely being sought by advocates in Sheridan's home state of California, he tells Addiction Professional. State legislation to bring that about is under consideration in the current session.
Utah in 2014, on the other hand, enacted mandatory licensure for recovery homes. But Sheridan says the GAO report fails to mention that the state has been enjoined from enforcing this because a federal court ruled that the measure runs afoul of the Fair Housing Act.
Ohio seeks to encourage sober home operators to obtain certification from the state's NARR affiliate, but the state did not establish a certification program by law because leaders did not want to create any roadblocks to development of more homes, the GAO report states.
As for NARR's perspective on regulation, “We recommend regulation with a light hand, at least to start,” Sheridan says. More regulation generally means more costs for operators, and this tends to disproportionately affect lower-cost operations that house some of the most challenging individuals in recovery, he says.
The GAO report also addresses funding, citing two ways in which states in theory can use federal money to encourage development of recovery housing: a pool of loan money under the federal substance abuse block grant, and funds under the State Targeted Response to the Opioid Crisis grant program. Sheridan says, however, that the permitted uses of those federal funds are fairly limited. “You can't use them to acquire a building, for example,” he says.
Texas has used at least $150,000 a year in the loan funding under the Substance Abuse and Mental Health Services Administration (SAMHSA) to increase the number of Oxford House operations in the state, while Ohio used a small amount of opioid grant money to train recovery housing operators. But Ohio at the same time has offered a great deal of state support to grow the recovery housing community. “They have smothered the community with resources and love, in a very good way,” Sheridan says.