Existing law requires the State Department of Health Care Services to license and regulate substance use disorder programs and facilities, as specified, and provides various programs for education about and treatment of substance use disorders.

This bill would state the Legislatures long-range goals through the creation of one-year and five-year plans to expand the substance use disorder treatment workforce in California to aid in the treatment of alcohol and drug abuse. The bill would set out one-year goals for school districts, the California State University system, the University of California, the community college system, and the department. The bill would also set out five-year plans to be created by the department, in collaboration with other state agencies, including coordination with the Office of Statewide Health Planning and Development (OHSPD) to administer grants, stipends, and loan repayment programs for counselors, peers, and licensed professionals who enroll in addiction-related coursework, with special emphasis on applicants who are able to fill identified cultural, linguistic, and geographic shortage areas.

This bill would make these provisions inoperative on July 1, 2023, and would repeal it as of January 1, 2024.

Date of Hearing: April 18, 2018

ASSEMBLY COMMITTEE ON APPROPRIATIONS

Lorena Gonzalez Fletcher, Chair

ABPCA Bill Id:AB 2804

Author:(Waldron) – As Introduced Ver:February 16, 2018

Urgency: No State Mandated Local Program: No Reimbursable: No

SUMMARY:

This bill states intent to achieve nearly twenty separate one-year and five-year goals related to the state's substance use disorder treatment workforce. These goals include the following:

1. School district and higher education system reporting on a number of metrics related to substance use prevention activities.
2. A statewide needs assessment of the substance use disorder workforce in each county.
3. The adoption of standards for peer specialists and intervention specialists.
4. Coordination in administration of grants, stipends, and loan repayment programs for counselors, peers, and licensed professionals.
5. Development of a methodology for factoring increases in county staff budgets to account for increases in salaries to support different staff certification levels.
6. A plan for a statewide education and training program for medication-assisted treatment training.

FISCAL EFFECT:

Although the bill does not require state agencies to take action, it creates significant GF cost pressure to meet enumerated goals. For instance:

1. To meet some of these goals, the Department of Health Care Services would incur at least $1.5 million GF in administrative costs for one to two years related to a statewide needs assessment, a quality assessment of substance use counselors, regulatory changes, oversight of certifying organizations, and stakeholder engagement. Ongoing costs in subsequent years would be somewhat lower as one-time workload is completed.
2. A reporting mandate on school districts and institutes of higher learning could result in cost pressure in excess of $1 million one-time to reimburse these entities.

Many of the individual goals, such as a statewide education and training plan, are open-ended and could scale to resources available. Other individual goals, such as that related to administration of grants, stipends, and loan repayment programs, would likely have significant costs in the millions of dollars.

COMMENTS:

1. Purpose. This bill is sponsored by the California Consortium of Addiction Programs and Professionals. It is intended to expand and improve the substance use disorder workforce. It has no opposition.
2. Background. Currently, California has approximately 36,000 registered or certified counselors working in more than 2,500 private and publicly funded drug and alcohol programs. In recent years, an epidemic of opioid addition and a significant expansion of health care coverage for substance use treatment have put pressure on the treatment system and workforce. The federal Substance Abuse and Mental Health Services Administration (SAMHSA) has noted complaints about workforce shortages in the substance use treatment field. In addition, California has not yet adopted a SAMHSA-recommended career ladder for substance use disorder certified and licensed personnel, a topic addressed in one of the goals.

Analysis Prepared by: Lisa Murawski / APPR. / (916) 319-2081

Date of Hearing: April 3, 2018

ASSEMBLY COMMITTEE ON HEALTH

Jim Wood, Chair

ABPCA Bill Id:AB 2804

Author:(Waldron) – As Introduced Ver:February 16, 2018

SUBJECT: Substance use disorder treatment workforce expansion.

SUMMARY: Specifies legislative intent to establish one-year and five-year plans aimed at expanding the substance use disorder (SUD) treatment workforce in California to aid in the treatment of alcohol and drug abuse. Specifically, this bill:

1. Repeals expired provisions establishing long-range goals of a five-year master plan to eliminate drug and alcohol abuse in California that became inoperative on July 1, 2013, in most part because its objectives were achieved.
2. Specifies legislative intent to achieve the following one-year goals:
   1. Require each school district with kindergarten and grades one to 12, the California State University system, the University of California, and the California Community College systems to report to the Department of Health Care Services (DHCS) on:
      1. The number of paid and volunteer hours used by the respective systems for alcohol and drug use prevention activities;
      2. The 2016-17 budget allocations for alcohol and drug use prevention activities; and,
      3. The official policies regarding rules for employing alcohol and drug use prevention professionals and SUD treatment professionals.
   2. Require DHCS to perform all of the following:
      1. Conduct a statewide needs assessment report evaluating the state of the SUD workforce in each county focusing on SUD services provided to youth;
      2. Conduct a quality assessment for addiction treatment prevention and integrated workforces that includes a sunrise review assessment for addiction counselors;
      3. Requires that certifying organizations approved by DHCS formalize a career ladder for addiction professionals that encompasses registrant through master’s level counselors; and,
      4. Adopt standards for peer specialists and intervention specialists, so that those specialists can be included in regulations for certifying organizations.
3. Specifies legislative intent to, in collaboration with other state agencies, create the following five-year plans for:
   
   1. A statewide Medi-Cal incentive program for federally qualified health centers and other Medi-Cal providers to implement and widely utilize the new Screening, Brief Intervention, and Referral to Treatment (SBIRT) adolescent tool, Facilitating Change for Excellence (FaCES) in the SBIRT practice;
      
   2. Implementation of fee waivers to help individuals in communities disproportionately impacted by the war on drugs to cover costs related to certification and testing for positions in the SUD treatment profession;
      
   3. Administration, in coordination with the Office of Statewide Health Planning and Development (OSHPD), of grants, stipends, and loan repayment programs for counselors, peers, and licensed professionals who enroll in addiction-related coursework, with special emphasis on applicants who are able to fill identified cultural, linguistic, and geographic shortage areas;
      
   4. The startup, training, and ongoing operation for participation in an Extension for Community Healthcare Outcomes (ECHO) program;
      
   5. Provision of funding to compensate for provider time to encourage the use of ECHO programs;
      
   6. Implementation of extended behavioral health and SUD training for licensed and certified providers in underserved and rural areas;
      
   7. Implementation of SUD training programs in communities that were disproportionately impacted by the war on drugs to become peers, counselors, and community health workers (CHW) and promotores;
      
   8. Review of the strategies for obtaining funding for clinics in underserved areas to utilize peers, CHWs, and promotores;
      
   9. Development of a structured English learner counselor development career path that takes into account the need to effectively communicate clinically;
      
   10. Encouragement of the development of a variety of alternate language curricula for clinical and nonclinical professionals, including counselors, peers, navigators, and community health workers;
       
   11. Development, in conjunction with national and state organizations, of a matrix to assess a SUD treatment program’s ability to address both sexual orientation and gender identification issues of individuals receiving services;
       
   12. Staff certification goals for each county and development of a methodology for factoring increases in staff budgets to account for increases in salaries to support these levels via future Drug Medi-Cal (DMC) Organized Delivery System waiver provisions; and,
       
   13. A statewide education and training program for medication assisted treatment (MAT) training that would increase the number of counselors and licensed professionals with a specialty certification in MAT.
       
4. Intends that the implementation of the one-year and five-year plans be subject to the budget review process.
   
5. Provides that these provisions become inoperative on July 1, 2023, and, as of January 1, 2024, is repealed.

EXISTING LAW:

1. Establishes the Medi-Cal program, administered by DHCS, under which qualified low-income individuals receive health care services, including substance abuse services under the DMC program.
2. Gives DHCS the sole authority to determine the qualifications, including the appropriate skills, education, training, and experience, of personnel working within alcoholism or drug abuse recovery and treatment programs licensed, certified, or funded by DHCS.
3. Requires DHCS to require an individual providing counseling services be registered with or certified by an organization approved by DHCS to register and certify counselors.
4. Prohibits DHCS from approving a certifying organization that does not, prior to registering or certifying an individual, contact other DHCS-approved certifying organizations to determine whether the individual has ever had his or her registration or certification revoked.
5. Requires, if a counselor’s registration or certification has been previously revoked, the certifying organization to deny the request for registration and to send the counselor a written notice of denial.
6. Defines SUD counselor as a person who is certified as an alcohol or other drug counselor by an approved certifying organization and who provides services or treatment at an adult alcoholism or drug abuse recovery or treatment facility.
7. Gives DHCS the sole authority to license facilities providing 24-hour residential nonmedical services to eligible adults who are recovering from problems related to alcohol or other drug (AOD) misuse or abuse. Requires licensure when at least one of the following services is provided: detoxification; group sessions; individual sessions; educational sessions; or, alcoholism or drug abuse recovery or treatment planning. 
8. Establishes OSHPD, under which data is collected, analyzed, and published about California's healthcare workforce and health professional training, identifying areas of the state in which there are shortages of health professionals and service capacity, and coordinating with other state departments in addressing the unique medical care issues facing California's rural areas.

FISCAL EFFECT: This bill has not yet been analyzed by a fiscal committee.

COMMENTS:

1. PURPOSE OF THIS BILL. According to the author, there are almost 3.5 million people with diagnosable SUDs in California, yet there are less than 20,000 certified SUD treatment counselors. California employs fewer SUD counselors per population than the national average. In order to increase access to SUD treatment in California, the state must also increase the number of trained professionals to provide treatment.
   
   The author contends that efforts being made with current legislation will be futile unless there is an educated and accessible workforce ready to address the needs of Californians receiving substance use treatment. Expanding and improving the SUD workforce supports the goal of creating the nation’s first “on demand” treatment system for SUD and creates the foundation for California’s youth treatment system set to be implemented in 2019.
   
   The author states that this bill would assist the administration in defining workforce priorities prior to the allocation of Proposition 64 funds, thereby ensuring that there are a sufficient number of competent SUD counselors to treat the growing number of opioid dependent adults and youth, as well as youth and adults to age 26 who may be treated with revenue generated by the legalization of retail cannabis.
2. BACKGROUND. California and the nation as a whole are experiencing an opioid epidemic. For the 24 month period of July 2015 through July 2017, over 9,000 Californians lost their lives as a result of drug overdoses, a trend primarily driven by opioids including heroin and fentanyl. Alcohol and drug dependency are treatable conditions, requiring extensive treatment and customized care. As individual problems, needs, and resources vary from individual to individual, a variety of treatment strategies must also be available if the needs of citizens are to be met.
   
   The increased demand for SUD treatment as a result of the opioid epidemic and the expansion of individuals having insurance as a result of health care reform has placed a growing burden on the existing SUD treatment community. Currently, California has approximately 36,000 registered or certified counselors working in more than 2,500 private and publicly funded drug and alcohol programs, ranging from residential rehabs to driving under the influence and outpatient programs.
   1. Current Certifying Organizations. Currently DHCS authorizes two (down from a high of more than a dozen) different certifying organizations to certify counselors. Each program develops its own classroom curriculum, training, supervisor, and work experience requirements meeting the department’s requirements of a minimum of 155 documented hours of formal classroom alcohol and other drug (AOD) education, a minimum of 160 documented hours of supervised AOD training and supervised on-site by an AOD counselor who has been licensed or certified, 2,080 or more documented hours of paid or unpaid work experience providing counseling services in an AOD program, and a score of at least 70% on a written or oral examination approved by the certifying organization. DHCS recognizes the following two National Commission for Certifying Agencies accredited organizations for the purpose of registering and certifying AOD counselors in California:
      1. California Association of DUI Treatment Programs Accredited Program: Certified Alcohol & Other Drug Counselor (Expires 6/30/18); and,
      2. California Consortium of Addiction Programs and Professionals (Expires 4/30/22).
   2. Substance Abuse Mental Health Services Administration (SAMHSA). In 2011, in response to the Patient Protection and Affordable Care Act as well as the Mental Health Parity and Addiction Equity Act expanding access and coverage for SUD treatment, SAMHSA convened key stakeholders to develop a model career ladder for SUD treatment workers. These stakeholders included representatives from higher education, the National Association of State Alcohol/Drug Abuse Directors, the State Association of Addiction Services, the International Certification and Reciprocity Consortium, the National Association of Addiction Professionals, and the Addiction Technology Transfer Center network. The recommendations were published in a document titled, “Scopes of Practice and Career Ladder for Substance Use Disorder Counselling,” which provides a framework and a guide for states to develop their own SUD scopes of practice and career ladders to meet the needs of their specific jurisdictions.
   3. ECHO Programs. Project ECHO is a collaborative model of medical education and care management founded at the University of New Mexico Health Sciences Center that is being modeled around the country. ECHO empowers clinicians everywhere to provide better care to more people, right where they live.
      
      The ECHO model does not actually “provide” care to patients. Instead, it dramatically increases access to specialty treatment in rural and underserved areas by providing front-line clinicians with the knowledge and support they need to manage patients with complex conditions such as: hepatitis C, HIV, tuberculosis, chronic pain, endocrinology, behavioral health disorders, and many others.  It does this by engaging clinicians in a continuous learning system and partnering them with specialist mentors at an academic medical center or hub.
   4. Senate Report. A 2013 report by the California Senate Office of Oversight and Outcomes extensively examined the current process to become an SUD counselor, and noted some of the systemic flaws. California is one of only two states among the nation’s 15 largest that makes no attempt to review counselors’ criminal backgrounds. Even within California, SUD counselors are the only health-related profession not required to undergo these checks. The ability to evade regulators represents a loophole. While the state’s two certifying organizations are required to check with their counterparts to see if a counselor has ever had their certification revoked, the regulation state this must be done only upon certification. Individuals registered to become counselors (registrants) may work for up to five years before they must become certified meaning that a counselor whose certification was previously revoked by another certifying agency could go as long as five years without being detected.
   5. The Adult Use of Marijuana Act (AUMA) 64/60. Most, if not all, of the advisory recommendations contained in this bill were developed by the AUMA 64/60 Workforce Committee. AUMA 64/60 is a grassroots organization comprised of individuals representing stakeholders from the full spectrum of communities and constituents impacted by the implementation of Proposition 64, AUMA. The “60” number in AUMA 64/60 represents California’s commitment to the allocating of significant tax revenues to the Youth Education, Prevention, Early Intervention, and Treatment (YEPEIT) account. The organization includes representatives from addiction treatment, mental health, youth services, addiction medicine, primary care medicine, prevention, education, criminal justice and community organization fields. Each representative participates voluntarily to achieve the following goals:
      1. Prepare for the impact that legal, recreational use of cannabis will bring to communities;
      2. Provide a unified voice in making recommendations for allocating tax revenue from the initiative so that it benefits California’s citizens and achieves the goals intended by the proposition; and,
      3. Gather ideas and input from the best minds in California regarding prevention, education, and treatment for youth who are in need of addiction services in California in order to build a national model for creating a health youth population in relation to substance use.
3. SUPPORT. The California Consortium of Addiction Programs and Professionals, sponsors of this bill, state that the bill will create planning for a 21^st Century SUD workforce to address the opioid crisis. The support states that Californians willing and ready to enter treatment die while waiting for openings at treatment programs. Forty-one percent of the SUD treatment workforce is identified as “registered” (have not met testing and education requirements). Registrants are considered “entry level” employees, yet they may continue to work in the status of registrant for five years. Employers cannot fill staff vacancies to meet demand for services, while low wages and high turnover created by the lack of a career ladder and disjointed professional standards plague the addiction treatment job market.
4. RELATED LEGISLATION.
   1. AB 2214 (Rodriguez) establishes a voluntary certification process for recovery residences and would require specified entities or persons who direct individuals into substance use treatment, or a judge or parole board, to first refer a person to a residence listed as a certified recovery residence. AB 2214 passed out of Assembly Health Committee and is now before Assembly Appropriations.
   2. AB 700 (Jones-Sawyer) of 2017 establishes classifications for SUD counselor certification, registrants, and interns using federal SAMHSA recommendations. AB 700 is pending in Senate Health Committee.
5. PREVIOUS LEGISLATION.
   1. SB 570 (DeSaulnier) of 2014 would have established a licensing and certification system for alcohol and drug abuse counselors to be administered by DHCS. AB 570 was held in the Senate Appropriations Committee.
   2. AB 2007 (Williams) of 2012 would have established a licensing and certification system for SUD counselors to be administered by the Department of Public Health. AB 2007 was held in Assembly Health Committee.
      
   3. SB 1203 (DeSaulnier) of 2010 would have instituted a licensing and certification structure for AOD counselors by Department of Alcohol and Drug Programs (DADP). SB 1203 was held in the Assembly Rules Committee.
      
   4. SB 707 (DeSaulnier) of 2009, which was substantially similar to SB 1203, died on the Assembly Appropriations Committee Suspense File.
   5. AB 239 (DeSaulnier) of 2008, would have established two categories of licensed alcoholism and drug abuse counselors for persons licensed to practice alcoholism and drug abuse counseling under clinical supervision, and persons licensed to conduct an independent practice of alcoholism and drug abuse counseling, and to provide supervision to other counselors, both to be overseen by the Department of Consumer Affairs Board of Behavioral Sciences. AB 239 was vetoed by Governor Arnold Schwarzenegger who stated, in his veto message, that he was directing DADPto craft a uniform standard for all alcohol and drug counselors whether in private practice or in facilities.
6. POLICY COMMENTS. This bill states that funding for the implementation of the one-year and five-year plans is subject to the budget review process but does not specify the source of funding. A potential source of this funding may be the California Marijuana Tax Fund (Fund) created by AUMA, specifically the YEPEIT account which, when tax revenues begin to be disbursed will be transmitted to the DHCS for further distribution. As this bill moves forward the author may wish to consider funding this bill through the Fund.

REGISTERED SUPPORT / OPPOSITION:

Support

California Consortium of Addiction Programs and Professionals (sponsor)

Community Recovery Resources

One Individual

Opposition

None on file.

Analysis Prepared by: Judith Babcock / HEALTH / (916) 319-2097