A California state Assembly bill that had been touted as “career ladder” legislation for addiction counselors passed by a 70-4 vote at the end of May, but bill author Reggie Jones-Sawyer pulled the legislation as it was headed to the state Senate. This came as good news to the California Consortium of Addiction Programs and Professionals (CCAPP), which was firmly opposed to AB 700. CCAPP actually considered the legislation to be a “counselor demotion” bill.
“It was a good idea to have a career path,” CCAPP CEO Pete Nielsen tells Addiction Professional. “But they tried to move too far too fast, and were trying to create a career path without any infrastructure, because there wasn’t any money.”
The career path would have had a hollow meaning, says CCAPP, because the state's treatment system wasn’t going to be given any more money. Costs for the career ladder would have come out of an already underfunded system and out of counselor’s pockets, according to the association.
CCAPP and other groups are now backing the California Comprehensive Addiction Recovery Act (C-CARA), a comprehensive initiative that would make addiction treatment available on demand for anyone in the state who needs it. A package of bills, the initiative also would focus on addressing ethical problems in the industry, including patient brokering, insurance abuses, and flagging counselor competency.
Competency, with funding
CCAPP knows that it doesn’t help treatment centers—or patients—to have counselors in the field who are not competent.
“Our ultimate goal is to have a career ladder with licensure at the top,” says Nielsen, noting that this is the way it works in most states. “But it needs to be where individuals not only acquire education and experience as they progress, but they get wages to match that.” This means the public system, which in California is administered on a county-by-county basis, needs to have sufficient funding.
“There are some drug and alcohol programs in California that only get 38 dollars from the county per bed for residential [treatment]. You can’t even get a Motel 6 for that,” says Nielsen.
These programs can’t afford to pay their staff very much, which means their employees are mainly entry-level, or are stuck in a position and unable to move up no matter how much education and experience they get, says Nielsen. “If they do move up, they move out of the industry altogether,” he says.
CCAPP's goal, says Nielsen, is to increase per-bed reimbursement. Under the state’s 1115 Medicaid waiver from the federal Centers for Medicare and Medicaid Services (CMS), California developed an organized delivery system, in which state Medi-Cal dollars are distributed to the counties. However, not all 57 counties participate in the waiver.
So typically, most of the money for the public system comes from the federal Substance Abuse Prevention and Treatment (SAPT) block grant, said Nielsen. The SAPT block grant is typically used for recovery housing, he says. “We can’t use Medicaid dollars for room and board.”
Problems with AB 700
Lack of money was at the crux of the provider community's problems with AB 700. “If someone is only making $15 an hour but they have a master’s degree, that’s not going to work very well,” says Nielsen. “It may work in the foster care system where counselors make more money once they get the degree.”
Without licensure at the top, a career path is not worth much, says Nielsen. “It doesn’t support individuals going through the system, and it doesn’t expand the workforce,” he says.
Under AB 700, all counselors without degrees, regardless of their years of service or skill and accomplishment, would have been relegated to the bottom of the career ladder. This includes all presently credentialed counselors, who would have lost their jobs if they didn’t have degrees. Bill opponents say the legislation would have led to a downward spiral in pay for experienced counselors—with the degreed but less experienced counselors taking their place.
A legitimate career ladder means you can start in the business on the bottom without full education, gain education as you gain experience, and be rewarded if you are good at your job and obtain the degree.
Many treatment programs are using therapists who are trained and licensed, but not in substance use disorders, says Nielsen. “There should be competency,” he says. “This population is a very difficult population to work with. And if you don’t have special knowledge and skills and abilities, you may be doing that population a disservice and causing further harm.”
Taking a broad view
In the future, it’s essential that counselors and treatment programs collaborate on legislation that benefits patients and the field as a whole, says Nielsen. “We’re taking on the patient brokering issue, hoping to get rid of it,” he says. “Our whole goal is to upgrade addiction treatment in California, so that people don’t have to be on a waiting list.”
Finally, Nielsen favors the county payment system, saying it has potential to be one of the best in the country. “I think the insurance system needs a lot of work,” he says. “It’s very cumbersome for providers and patients, especially in the addictions space. Then you have the fraud that does exist, which makes it worse—we have become penalized because of the bad actors.” In California, providers saw the fraud that was taking place and went to the legislature about it, he says.