With the passage of the Comprehensive Addiction and Recovery Act (CARA), implementation of the Patient Protection and Affordable Care Act (ACA), California’s Section 1115 waiver (Medi-Cal 2020), and possible adoption of the Adult Use of Marijuana Act by California voters in November, we are on the precipice of unprecedented change in the addiction treatment industry. Although increased focus and funding are positive developments, there are many potential problems that might arise if careful planning does not accompany these historic changes. Workforce shortages, insufficient treatment facility capacity, and oversight issues are of primary concern.
There are an estimated 3.5 million persons with a diagnosable substance use disorder (SUD) receiving treatment in more than 3,000 private or public alcohol and drug programs throughout the state. California is among a minority of states that do not have a state-administered licensing program for addiction professionals. This poses a major problem because absent a license requirement for professionals, anyone can practice addiction treatment in a private setting without oversight or demonstration of competency.
It is alarming, and indicative of the stigma that still exists, that someone can treat a life-threatening disease without a license. An unregulated private-practice system means no consumer protection from bad actors. In California there is only oversight in the public treatment system. This also means that if someone needs an addiction treatment professional in private practice, insurance companies will pay only for other professionals who are licensed, but these professsionals might not have competency in treating addiction (which could also cause harm).
“It is essential that service providers are trained alcohol and other drug (AOD) professionals and in milieus where AOD services are provided. Regardless of 'mental health primary' or 'chemical dependency primary' diagnoses, direct service providers must have education to support provision of services focused on AOD, including credentials articulating this education,” says David Skonezny, ethics chair for the California Consortium of Addiction Programs and Professionals (CCAPP).
Dangers of status quo
California addiction counselors providing services within the context of a public program are currently certified by one of three private certification organizations. Individuals providing services in private settings are not subject to licensure by the state or certification by a private certifying organization.
Christine Vestal, in an article published in Stateline in April 2015, articulated the impact of California’s inability to license AOD counselors. “Between now and 2020, the addiction services field will need to fill more than 330,000 jobs to keep pace with demand, of which more than half are the result of people retiring and switching to other occupations,” Vestal wrote.
This staggering number has a tremendous impact for California. Even worse is that a majority of funding sources require treatment centers to have treatment plans and diagnoses signed off on by licensed professionals as a condition of reimbursement. To meet the requirements for licensed staff, treatment facilities specializing in AOD treatment often will deliver services with licensed mental health professionals from other disciplines who require a mere 15 hours of drug and alcohol training—a phenomenon that defies logic to many treatment leaders.
“The population is vastly underserved. So no, there's not enough capacity,” Skonezny says. “The truth is there's a scarcity of financial resources. With the prevalence of CD-diagnosed people, service availability is paltry at best. Additional funding streams need to be put into place, generally to support this population and specifically to support ACA beneficiaries. This also begs the question of [behavioral health] parity and if we will ever get to the place where both diseases will be treated with the urgency they dictate.”
Skonezny adds, “We need more certified drug and alcohol counselors providing direct services at our facilities. However, we also need to have a licensed drug and alcohol counselor that can competently diagnose and sign treatment plans.”
Another missed opportunity
Back in April, an article published on the Addiction Professional website spelled out the need for Senate Bill 1101, to create licensure for addiction counselors in California, and reflected optimism in the state about the bill's prospects. However, the bill ended up not making it out of the Appropriations Committee in its house of origin. This was very unfortunate, because the bill would have represented a giant leap toward consumer protection and would have been an incredible help to solving the workforce shortage in California.
In order to address workforce shortages, lack of access to care, and other system shortcomings, legislation needs to be created that would create a simple and self-sustaining licensure program for California. From families suffering while loved ones go untreated, to politicians on the national stage, the drumbeat for more treatment has never been louder. In California it is imperative that we address the roadblocks to capacity expansion immediately. Treatment capacity equals two things: additional funding and workforce development. Where is the policy in California for either?
Pete Nielsen, MA, CADC II, is CEO of the California Consortium of Addiction Programs and Professionals (CCAPP).