California Sets the Stage for a Worldwide Treatment Revolution

From one hundred people and one Big Book to millions of recovering people spanning the globe, the history of addiction treatment and recovery has now come to converge in one place: California. After decades of constructive attempts to change the way people and policy makers view addiction and treatment, addiction profession leaders in California have seized upon a new approach to policy making that has the potential to lead the nation—and perhaps communities throughout the world—to a revolutionary way of approaching the disease: timely access to universal, on-demand treatment in every community.

California lawmakers are joining together to introduce a package of legislative bills addressing everything from insurance reform, to workforce professionalization, to the literal building (i.e., construction) of facilities to increase capacity in California, until there are no more waiting lists for treatment. 

“The idea is quite simple,” said California Consortium of Addiction Programs and Professionals (CCAPP) CEO Pete Nielsen. “We are no longer going to stand by while our brothers, sisters, daughters, and sons die from a treatable disease,” he added. 

Although addiction treatment is as old as Bill Wilson’s inklings from the 1930s, the thought that society can and should demand that no one dies from it, is a relatively new concept. 

CCAPP has drawn together treatment experts from throughout California to draft multiple bills that, as a package, are known as the California Comprehensive Addiction Recovery Act (C-CARA). The bills cover four main areas (pillars) aimed at making addiction treatment available to all Californians: physical capacity expansion, workforce capacity expansion, workforce professionalization, and payment reform/stigma reduction. The groundbreaking package proposes to bring addiction treatment on par with treatment for other ailments in every sense. 

“C-CARA will raise quality, expand access, and create an environment where people are free to come forward for treatment without fear of backlash from communities they live and work in,” said Nielsen.

Bills addressing each of the four pillars were drafted and submitted to the legislative counsel in Sacramento. Several authors considered which pieces they would like to take a leadership role in and a press conference to unveil the package was scheduled. Celebrities who support recovery were being contacted to attend the press conference and lend their voices to the passage of C-CARA. A legislative conference on March 21–22 drew supporters from throughout California to march the halls and draw attention to the monumental effort to reshape treatment. All of the measures will be trackable at ccara.info, where news releases, updates, and ways to support are detailed. 

The physical capacity pillar seeks to create the mechanisms necessary to finance construction and expand physical capacity for addiction treatment to meet requirements of the Affordable Care Act (ACA) and in preparation of the implementation of Proposition 64. It would maximize current capacity by removing inpatient licensing fees and providing per-bed bonuses for additional beds until capacity in the state reaches 150 percent of current levels. The legislation for this pillar begins the process of awarding grants and loans for construction of new treatment, detoxification, and recovery residence facilities. 

To combat NIMBY ordinances that constrict the establishment of new treatment and recovery programs in communities, legislation for this pillar adds addiction treatment and recovery as a category for density bonuses in new developments. To discourage illegal and costly local ordinances that conflict with state and federal disability laws, the legislation for this pillar gives groups of treatment and recovery residence owners the ability to seek injunctive relief from city and county ordinances that target addiction programs for special and conditional use permits. To assist communities and local governments in achieving capacity expansion, a local government guide for regulating addiction treatment and recovery will be created.

This pillar also would create a voluntary certification program for recovery residences in California and would prohibit referrals from addiction treatment programs to noncertified recovery residences. It defines a “recovery residence” as a residential property that meets specified requirements and is operated as a cooperative living arrangement to provide an alcohol- and drug-free environment for persons recovering from alcoholism or drug abuse, or both, who seek a living environment that supports ongoing recovery. The legislation for this pillar would provide that a recovery residence may be certified by an organization approved by the State Department of Health Care Services, defined as “an approved certifying agency” and would provide that a residence housing persons who purport to be recovering from drug or alcohol abuse would be presumed to be a recovery residence if the residence has been certified by an approved certifying organization. 

The workforce capacity pillar seeks to establish workforce expansion programming to increase the number of alcohol and other drug (AOD) counselors in California for the purpose of filling critical shortages and to prepare for the expansion of youth treatment created by the passage of Proposition 64. The legislation for this pillar would set priorities for the $10 million allotment earmarked by the initiative for professionalization of the workforce. To achieve this purpose, the legislation for this pillar would imitate the state’s outdated definition of “mental health providers” as it pertains to loan forgiveness and other educational incentives, to align with federal terminology like “behavioral health,” which includes mental health and substance use disorder careers, by renaming the “Licensed Mental Health Service Provider Education Program” the “Behavioral Health Service Provider Education Program.” This would provide access to federal critical shortage funding for AOD counselors. Additionally, the legislation for this pillar would address barriers to entry to the field of addiction counseling by providing waivers for certification and testing fees required to obtain state required certification. 

The workforce professionalism pillar seeks to license AOD counselors in California; provide for state-approved certification of peer support specialists, interventionists, and recovery coaches; and create a uniform career ladder for the profession. The legislation for this pillar would create a bureau to conduct many important functions related to licensure, including prohibiting practicing AOD counseling outside of a licensed or certified facility without a license (with some exceptions); standardizing criteria for qualifications for education, training, and experience for licensed counselors; allowing the Department of Consumer Affairs to conduct background checks on all individuals applying for a license to be an AOD counselor; and imposing sanctions on AOD counselors for misconduct and implementing an appeals process for those sanctions.

The licensure program would “grandparent” current counselors who are at an advanced level and have passed the IC&RC Advanced Alcohol Drug Counselor Examination within a specified time period. The license would be voluntary, allowing certified counselors to continue to work in licensed and certified facilities in California. 

The goal of the payment reform and stigma reduction pillar is to end waste and improve financial allocation to quality programs in reimbursement systems, while reducing overall stigma by increasing the public’s understanding of addiction as a public health issue. The legislation for this pillar would reform the private payment market for addiction treatment by prohibiting kickbacks to referring agents; regulating addiction treatment call centers; and prohibiting dangerous direct “pay-to-patient” policies that result in large cash payments being made to addicts in early recovery. It also brings experts in private industry and government together for task force meetings to share information about the current state of access to addiction care and parity implementation efforts in California. 

The taskforce created by the legislation for this pillar would provide important data about the way in which treatment is approved, methods for approving continuing or “step down” treatment, and the way in which disputed claims are managed.

The interesting facet of the C-CARA is its insistence that the state dedicate adequate financing to treatment. It puts forward some easy concepts for financing and some highly controversial ones, but does not begin with the premise that it goes away for lack of funding. 

“Appropriate funding is kind of the point,” said Nielsen. “As a society we never asked if we can afford to treat heart disease or diabetes. People would have been outraged. I believe we are there with this disease now,” he explained. 

The funding bill created for the C-CARA draws revenue from several sources. California passed Proposition 64, the Adult Use of Marijuana Act in November 2016. Sixty percent of the tax revenue from the initiative is allocated to addiction treatment. With an estimated $600 million in treatment dollars, per year, forever, C-CARA relies on revenue from the proposition for a number of priorities. Workforce capacity and physical capacity are earmarked directly by the initiative and C-CARA plans to lay claim to funding for these purposes. In advance of the initiative it calls for general fund borrowing with payback from marijuana tax revenue.

Having experienced the promises and pitfalls of funding from a previous proposition—Proposition 36, the treatment alternative to incarceration—addiction leaders are wary of putting all of C-CARA’s eggs in one basket. 

Proposition 64 directs funding to youth prevention, education, and treatment, meaning that more than one department and a vast array of stakeholders will be in pursuit of its revenue. Given this reality, C-CARA proposes additional funding sources that can be adjusted should marijuana tax revenue not fill the needs. Included in its funding provisions are a nominal administrative fee collected at admission to treatment in California—with an exemption for clients who have incomes less than 150 percent of the federal poverty level—and increased penalties for narcotics convictions. In addition to proposition funding, a treatment surcharge, and increased penalty assessments, CCAPP is working with stakeholders and legislative leaders to develop a long-term funding mechanism that may include increasing alcohol excise taxes or expanding the state’s CRV (bottle tax) to collect revenue dedicated to treatment.

C-CARA is an ambitious plan to move the disease and its treatment to a place that matches the changing views of the American public. Yet, at a time when every presidential candidate campaigned with platforms for better treatment, there are still no guarantees that lawmakers will deliver on C-CARA.

Win, lose or draw, 2017 will be the year that California faces addiction head on. As policy changes and develops, California demonstrates that, bit by bit, it can discard the old—the one that did not work—for the new, that can and does work under any conditions.