Date of Hearing: May 1, 2019

ASSEMBLY COMMITTEE ON APPROPRIATIONS

Lorena Gonzalez, Chair

ABPCA Bill Id:AB 1557

Author:(Chiu) – As Amended Ver:April 11, 2019

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

SUMMARY:

This bill requires, contingent upon appropriation, the Department of Health Care Services (DHCS) to establish a three-year pilot program for the City and County of San Francisco to receive funding to support medication-assisted treatment (MAT) of inmates confined in the city and county jail and who have a history of a substance use disorder.

FISCAL EFFECT:

$5 million GF to provide a three-year grant to the City and County of San Francisco for an MAT pilot project.

COMMENTS:

1. Purpose. This bill is sponsored by the San Francisco Department of Public Health to provide funding to increase the capacity to provide drug treatment in local jails.
2. Drug Treatment in Medi-Cal. Counties provide SUD treatment in Medi-Cal. Such treatment is “carved out” of contracted Medi-Cal managed care plans; programmatic and funding responsibility was realigned to counties through the state’s major 2011 criminal justice realignment. DHCS is in process of implementing a Drug Medi-Cal Organized Delivery System (DMC-ODS) to deliver a robust package of services at county option using county realignment and federal funds.

Regardless of the robustness of the service delivery system outside jails, however, individuals who are institutionalized are categorically ineligible to receive services through Medi-Cal, meaning counties cannot claim federal reimbursement for services delivered inside jails. There is also no mandate for jails to provide drug treatment to inmates and it is not commonly provided, despite dramatic overrepresentation of individuals with substance use disorders in jails. Health care treatment in jails, like other costs of housing and services for inmates, is a local responsibility.

1. Related Legislation. AB 914 (Holden), pending in this committee, extends Medi-Cal eligibility for individuals who are inmates of public institutions until the individual is no longer an inmate or no longer eligible, whichever occurs sooner.

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

Date of Hearing: April 9, 2019

ASSEMBLY COMMITTEE ON HEALTH

Jim Wood, Chair

ABPCA Bill Id:AB 1557

Author:(Chiu) – As Amended Ver:March 18, 2019

SUBJECT: Medication-Assisted Treatment Drug Reimbursement Pilot Program.

SUMMARY: Requires the Department of Health Care Services (DHCS) to establish a three-year pilot program to provide an option to a city, county, or city and county (an entity) to receive funding to support medication assisted treatment (MAT) of inmates confined in a city or county jail who have a history of substance use disorder (SUD). Specifically, this bill:

1. Requires DHCS to establish a three-year pilot program to provide an option to an entity to receive funding to support MAT of inmates confined in a city or county jail who have a history of SUD.
2. Requires funds allocated to an entity under this bill to be used to purchase medications for the MAT of inmates in the city and county jail.
3. Requires medication purchased under this bill for MAT to be approved by the U.S. Food and Drug Administration (FDA) for the treatment of SUDs and to include, but not be limited to buprenorphine products, methadone, and naltrexone, as specified.
4. Authorizes DHCS to enter into exclusive or nonexclusive contracts on a bid or negotiated basis in order to implement this bill.
5. Allows an entity to participate in the pilot program if it meets both of the following requirements:
   1. Has a screening and diagnostic strategy for identifying the target population early in its jail detainment process; and,
   2. Has an integrated SUD treatment program that begins in jail and continues through the transition back to the community.
6. Requires an entity participating in the pilot program to provide an annual report to DHCS that addresses all of the following:
   1. The number of persons participating in a jail system’s MAT program;
   2. The number of persons who withdraw from the MAT program against medical advice, and the number of persons who are discharged from the MAT program prior to achieving their treatment goals; and,
   3. The number of persons who are successfully linked to treatment post release.
7. Requires the local office that serves as the fund administrator to prepare the report under this bill.
8. Requires implementation of this bill to be contingent upon an appropriation in the annual Budget Act.
9. Sunsets the provisions of this bill on January 1, 2023.

EXISTING LAW:

1. Establishes the Medi-Cal program, administered by DHCS, under which qualified low-income individuals receive health care services.
   
2. Establishes the Drug Medi-Cal (DMC) program that provides medically necessary SUD treatment services to eligible Medi-Cal beneficiaries for specific, approved services. Permits DHCS to enter into contracts with each county, or enter into contracts directly with certified MAT providers, for the provision of various alcohol and drug use treatment services, including SUD services.
3. Establishes the Drug Addiction Treatment Act which permits qualified physicians to provide MAT for narcotic dependence with Schedules III through V narcotic controlled substances that have been approved by the FDA for that indication.
4. Requires licensed narcotic treatment programs (NTPs)to use specified narcotic replacement therapy and MAT, including buprenorphine products and methadone, in the treatment of addicted persons

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

COMMENTS:

1. PURPOSE OF THIS BILL. According to the author, overdose deaths and hospitalizations from opioids present a serious public health crisis in California. In 2017, almost 4,000 Californians were hospitalized due to an opioid overdose, and over 2,000 died. According to the California Department of Public Health, 70% of these deaths involved prescription opioids. MAT for SUDs combines counseling and behavioral therapy with the use of FDA approved medications in a “whole patient” approach. These FDA approved medications reduce cravings and feelings of withdrawal and stabilize the abnormal brain chemistry created by addition to opioids. As a result MAT significantly improves the chances a patient will stay in treatment and reduces the risk of overdose death. Numerous studies have shown that MAT is a more effective intervention tool to treat an opioid use disorder that behavioral interventions or medications alone. Recent studies have demonstrated that exposure to MAT programs during incarceration can reduce deaths and drug-related poisonings. Furthermore, studies have indicated that MAT can be cost effective and may reduce re-entry in the criminal justice system. The author states that California must take creative steps to end the addiction crisis in our communities.
2. BACKGROUND.
   1. MAT in the criminal justice setting. A 2013 study published in the National Center for Biotechnology Information entitled, “Medication-Assisted Treatment in Criminal Justice Agencies Affiliated with the Criminal Justice-Drug Abuse Treatment Studies: Availability, Barriers & Intentions,” reports that MAT is underutilized in the treatment of alcohol- or opioid-dependent, criminal justice populations despite substantial evidence of its effectiveness in reducing opioid and alcohol use, criminal behavior and arrest, and HIV risk behavior. According to the study, pregnant women and individuals experiencing withdrawal were most likely to receive MAT for opiate dependence in jail or prison, while those re-entering the community from jail or prison were the least likely to receive MAT. Factors influencing use of MAT included criminal justice preferences for drug-free treatment, limited knowledge of the benefits of MAT, security concerns, regulations prohibiting use of MAT for certain agencies, and lack of qualified medical staff.
      
      According to the 2013 study, the potential role of MAT for criminal justice populations is particularly germane today as numerous drug-involved inmates return to the community, and state budget crises provide impetus for evidence-based interventions like MAT to reduce the costs of rearrests and re-incarceration as well as the societal, human and health care costs associated with chronic substance dependence.
   2. California MAT Expansion Project. In an effort to address the opioid epidemic throughout the state, DHCS is implementing the California MAT Expansion Project (MAT Project). The California MAT Expansion Project aims to increase access to MAT, reduce unmet treatment need, and reduce opioid overdose related deaths through the provision of prevention, treatment, and recovery activities. The MAT Project also focuses on populations with limited MAT access, including rural areas and American Indian & Alaska Native tribal communities.
      
      The MAT Project is funded by the Substance Abuse and Mental Health Services Administration (SAMHSA) State Targeted Response grant and the SAMHSA State Opioid Response grant. Federal, state, and local attention is focused on slowing the epidemic of opioid addiction and overdose deaths. Research shows that a significant percentage of overdose deaths occur after release of individuals from corrections. Jails and prisons are increasingly being drawn into the arena of MAT, yet most do not have sufficient preparation, policies, or funds to adequately address needed changes. The MAT Expansion project provides technical assistance and resources for county-based teams for up to 20 California counties, with the goal of building capacity for California jails to maintain MAT prescribed in the community for detainees who become incarcerated and ensure best practices and approaches to MAT are used throughout the corrections process.
   3. California prisons. While pharmaceutical drug solutions have been around for years, up until now MAT has been reserved for only a few select institutions. A handful of California prisons launched programs in 2017, but county and city jails have yet to receive state funding for the medication and treatment, despite that it is arguably where it is most needed due to higher turnover. When people who use drugs are locked up, they emerge days, weeks, or months later with a weaker tolerance. If they use at the same dosage that they used to, there’s a high risk of fatal overdose.
      
      According to a recent article, San Francisco’s Department of Public Health has a long history of supporting harm reduction efforts for people who use drugs, and despite not having state funding for MAT programs in its jails, has been operating them for years with money from the city’s General Fund (GF). The limited funding has affected the scope of what jail health services can institute. Methadone treatment is provided for 250 patients a year, and buprenorphine for 600 patients, the latter at a cost of $46,000 annually. While this bill does not come with a set budget for county programs, there is a desire among San Francisco’s jail health workers to expand the scope of treatment, both to reach more people, and keep them on the medication for longer, not just for the unpleasant detox period.
      
      According to a Kaiser Health News article, at a time when the U.S. government is trying to deal with a nationwide opioid epidemic, many jails across the country are only now rolling out medicines to help inmates overcome addiction. And most of those jails dispense only one of the drugs currently available. Nearly one in five jail and prison inmates regularly used heroin or opioids before being incarcerated, making jails a logical entry point for intervention, according to the U.S. Department of Justice. Medication, when paired with counseling and social support, is considered the standard treatment for opioid addiction. Three medications treat addiction to opioids. Methadone and buprenorphine diminish opioid withdrawal symptoms and can reduce cravings. Naltrexone blocks the effect of opioids and also treats alcoholism. But cost and a long-standing belief that the best way to overcome addiction is abstinence are barriers to using any type of medication to help treat opioid addiction, experts said. In addition, methadone and buprenorphine require a special license to distribute and, to be an effective long-term solution, should be continued after many inmate patients are released.
      
      Several programs that provide MAT have demonstrated success, including ones in New York and Rhode Island. A small study on the Rhode Island program found a 60% reduction in opioid overdose deaths among recently freed inmates. In California, health care decisions in the jails are left to the counties, Los Angeles County is expanding its use of medication-assisted treatment. It currently offers naltrexone but is in the planning stages of offering buprenorphine and methadone. The state also is working to expand access to anti-addiction medications for inmates. DHCS recently announced that counties can apply for grants of up to $25,000 to learn how to effectively implement such treatment in jails and drug courts. The cost of providing methadone and buprenorphine can reach hundreds of dollars per inmate each month, in part because of the medical and security staffing needed to run the programs. Naltrexone, on the other hand, is much cheaper to provide. The company that manufactures the drug has provided it free to some jails.
3. SUPPORT. The Mayor of the City and County of San Francisco states that people with a history of substance use are significantly overrepresented in jails and prisons. In San Francisco, an estimated 80% of the 18,000 bookings in county jail in 2018 had a history of substance use. Incarceration can create significant risks for individuals with a history of substance use, including untreated withdrawal, disrupted treatment, and increased risk of overdose. These harms are primarily due to a lack of access to treatment while incarcerated. Although treatment for substance use is expanding throughout the state, county jails do not have any state or federally funded support to provide MAT to individuals in custody. The Mayor states that the provision of MAT medications in San Francisco County Jail are funded through the City’s GF because patients are not eligible to receive insurance coverage or pharmaceutical patient assistance programs while incarcerated. In addition, Medi-Cal does not provide reimbursement for medical services for the jail population, unless they are hospitalized. The Mayor concludes by stating that the fact this treatment is supported once an individual is released from jail, but not when they are in jail, makes little sense. We need to be doing everything we can to rehabilitate people, and substance use treatment while being incarcerated is a critical component of that rehabilitation.

The County Behavioral Health Directors Association (CBHDA) states that many counties are now recognizing that MAT is the most effective therapy for opioid addiction, and providing it is the right thing to do from a public health perspective. Additionally, if it can help reduce recidivism, it’s the right thing to do from a criminal justice perspective. CBHDA further states further that over 20 California counties have been attending learning collaboratives on initiating MAT in the jails, with attendees representing county health and behavioral health services, collaborative courts and probation. Some counties are working toward utilizing all three FDA approved medications for MAT, as well as providing programming and therapy in combination with medication. The funding available under this bill will support these counties in providing MAT services to eligible jail inmates.

1. RELATED LEGISLATION. AB 1031 (Nazarian) establishes the Youth Substance Use Disorder Treatment and Recovery Program Act of 2019. Requires DHCS to establish community-based nonresidential and residential treatment and recovery programs to intervene and treat the problems of alcohol and drug use among youth under 21 years of age. AB 1031 is pending in the Assembly Appropriations Committee.
2. PREVIOUS LEGISLATION.
   1. AB 532 (Waldron) would have authorized a court to develop a program to offer mental health and addiction treatment services, as defined, to women charged with specified non-felony complaints. AB 532 was vetoed by the Governor.
   2. AB 395 (Bocanegra), Chapter 223, Statutes of 2017, added the use of MAT as an authorized service by NTPs licensed by DHCS; modified the specific controlled substances authorized for use by licensed NTPs for narcotic replacement therapy MAT to instead allow medications approved by the FDA for the purpose of narcotic replacement treatment or MAT for SUDs; and refer to medications, rather than controlled substances.

• 1. AB 417 (Beall) of 2009 would have established a buprenorphine MAT pilot program under DMC for the purpose of determining the efficacy of buprenorphine in treating opioid addiction. Would have required all NTPs participating in the pilot program to operate in accordance with prescribed requirements; and, authorized the use of buprenorphine and any other federally approved controlled substances used for the purpose of narcotic replacement treatment. AB 417 was held on the Senate Appropriations Committee suspense file.

1. AUTHOR AMENDMENTS. The author has agreed to amend this bill to address Committee concerns, as follows:
   1. The pilot program will be limited to the City and County of San Francisco.
   2. The requirements of the annual report to be submitted by the City and County of San Francisco to DHCS have been expanded to include, but not be limited, to the following items:
      1. The number of persons participating in jail system’s medication-assisted treatment program;
      2. The number of persons who required withdrawal treatment for opioid use and the number of buprenorphine and methadone doses administrated in the year prior to the start of the pilot program;
      3. The number of persons who withdraw from the medication-assisted treatment program against medical advice, and the number of persons who are discharged from the medication-assisted treatment program prior to achieving their treatment goals;
      4. The length of participation for persons who receive treatment in the program;
      5. The number of persons who are successfully linked to treatment post release; and,
      6. The rate of recidivism back into the justice system for persons who participate in the program compared to the rate of recidivism back into the justice system for the general population.
   3. DHCS will also be required to submit a report to the Legislature upon completion of the pilot program that includes an evaluation of the program and outcomes achieved.

REGISTERED SUPPORT / OPPOSITION:

Support

London N. Breed, Mayor, City and County of San Francisco

County Behavioral Health Directors Association

Drug Policy Alliance

Opposition

None on file.

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