Seems that dead bodies, overdoses and insurance fraud aren’t quite enough to spur California to overhaul its private-pay addiction treatment system, but hats off to the legislators who keep trying, year after year after year.
Actually, as of late, reformers in Sacramento seem to be gaining some traction, with four of 12 bills advancing and perhaps even landing on the governor’s desk. We celebrate this, while mourning the eight that seem stuck, at least for now. Some would have spurred much-needed change to protect vulnerable users, and the neighbors who find themselves living beside tract homes where recovering users try to furnish what’s often life-or-death care.
The bills with the most juice spring from a critical state audit of the Department of Health Care Services (which licenses and regulates non-medical addiction treatment centers). The audit found serious problems, including crazy long lag times for investigating urgent complaints (almost three months for high-priority situations, such as patient deaths) and more than a year for less dire complaints (meaning problems can fester and put patient safety at risk).
It also found that when the state brought its weight to bear on unlicensed homes illegally providing services, regulators didn’t always bother to venture out to see for themselves what was actually happening, and/or didn’t follow up to make sure the folks they told to stand down actually stood down.
And while California aims to de-institutionalize mental health care, the audit found that big addiction treatment “campuses” spring up in residential neighborhoods anyway as providers cluster many small homes together — one treating 30 users at a pop — while regulators fail to raise an eyebrow.
The political heft of the League of California Cities has helped push the reform agenda forward this session. It has thrown its weight behind four bills, two of which are progressing toward the finish line.
“We’ve been working on this issue for over a decade, and I do think we’re seeing more progress than we’ve seen in the past 10 years,” said the League’s Caroline Grinder. “It does seem like we’re building momentum.”
The work of the California Sober Living and Recovery Task Force — now a bona fide nonprofit — has helped, she said, as have the heartbreaking stories of actual people caught up in “The Shuffle.” Some never make it out alive.
Looking hopeful
Assemblymember Laurie Davies, R-Laguna Niguel, gave us Assembly Bill 424, which aims to address the crazy lag on complaints. It would require Health Care Services to communicate better with people who lodge complaints, acknowledging their receipt within 10 days and then informing those folks when the investigation is done and if violations were discovered. The proposal flew through the Assembly, passed the Senate and is on its way to the governor’s desk. It’s sponsored by the League of California Cities.
In the “Tell us what you know rather than keeping us like mushrooms in the dark” file is Senate Bill 83, from Sen. Tom Umberg, D-Santa Ana. It would require DHCS to actually publicize information that’s vital but notoriously hard to get, by posting a summary of each violation issued to licensed and/or certified addiction treatment facilities on its “Probationary Status, Temporary Suspension Order, Revoked and Notice of Operation in Violation of Law Program List.” The bill also would require DHCS to explain that sober homes found to be providing treatment without a license are not included on that list. The bill passed the Senate and appears on track for approval in the Assembly.
Facilities open and close with some regularity, but local governments are often in the dark about precisely where they are and who owns them. The League of California Cities -sponsored AB 492, by Assemblymember Avelino Valencia, D-Anaheim, with principal coauthor Umberg (and co-authors Davies and Assemblymembers Diane Dixon, R-Newport Beach, Cottie Petrie-Norris, D-Irvine, and Kate Sanchez, R-Rancho Santa Margarita, for a show of bipartisan legislative force), would require the state to notify a city or county when a rehab license is issued in its boundaries. That notification would have to include the name and mailing address of the person holding the license, as well as the facility’s location. It made it through the Assembly and Senate and is on its way to the governor’s desk.
Did a facility’s practices contribute to a resident’s death? Exactly what’s being done to prevent it from happening again? Dixon’s AB 1356 would require facilities with deficiencies to follow-up with DHCS within 60 days of a resident’s death. They’d have to supply updated information on the events surrounding the death, and on any action being taken to prevent repeats. The bill passed the Assembly and got a thumbs up from the Senate health and appropriations committees.
Facing headwinds
These perhaps-more-ambitious bills definitely face more opposition. Some will be back in the next session — and deserve to pass.
One is SB 329, by Sens. Catherine Blakespear, D-Encinitas, and Umberg (co-authored by Assemblymembers Davies and Dixon), and backed by the League of California Cities. The fact that it takes the state more than a year to investigate some complaints is simply unacceptable, the authors said, and their bill would require more timely investigations, but only by adhering to DHCS’s own internal guidelines. It means DHCS would have to assign complaints to staff within 10 days of receipt, and complete investigations within 60 days. The bill passed out of the Senate with no opposition, but was placed in the Assembly’s dreaded appropriations suspense file. A hearing slated for Aug. 29 was postponed.
DHCS says doing its job the way it’s supposed to would require an additional 31 positions — more than doubling the unit’s staff — and cost millions of dollars. Grinder, from the California League of Cities, said it’s a two-year bill and work will continue on it in the next session.
Perhaps our biggest personal disappointment is the stall of SB 35 by Umberg, with Assembly coauthors Joe Patterson, R-Rocklin, and Pilar Schiavo, D-Chatsworth, and sponsored by the League of California Cities. The state is clearly saying it’s not equipped to swiftly respond to complaints — see above — but it also doesn’t want anyone else to help, either.
SB 35 would strengthen oversight by empowering local governments to get permission to step in and do the work if the state is too short-handed — but only under certain conditions. It would require DHCS to conduct a site visit, or allow a county to conduct a site visit, if a sober home is alleged to be providing services it’s not licensed to provide. That visit would have to happen within 10 days of receiving an allegation, and investigations would have to be completed within 60 days.
The bill would require an on-site follow-up visit — which the audit found wasn’t happening — and, importantly, would also require treatment programs to report money transfers between themselves and sober living homes as a way “to detect patient brokering, illicit kickbacks, or unethical inducements that harm patients.” (The state has been collecting spotty information on treatment by facility-sober home ties for years but doing nothing with it; this bill would require DHCS to analyze data and develop guidelines for permissible and impermissible transfers.)
SB 35 passed the Senate but was placed in the dreaded Assembly appropriations suspense file, then held in committee last month. It is a reincarnation of Umberg’s eminently sensible SB 913, whose death we took quite personally, and we fully expect to see a new version of it in the not-too-distant future.
“I’m deeply disappointed that SB 35 did not advance this session,” said Umberg by email. “The crisis in our addiction treatment system is real, and lives are at stake. Recovery is possible, but only when care is ethical, safe, and truly centered on the needs of patients. We must do better — and we will continue this work.”
(A plea: get over the control freak thing, DHCS. The state empowers local police to enforce the laws and all hell hasn’t broken loose. You can empower local governments to do the same.)
On the over-concentration and “battling re-institutionalization” front, Dixon’s AB 3 would require physical distance between recovery or treatment homes. Such businesses wouldn’t be considered a “residential use of property” — which is protected by law — if multiple single-family dwellings are used as recovery facilities; if they share an owner, director, programs, or amenities with another facility, and are within 300 feet of it; or if a single-family dwelling shares an owner, director, programs or amenities with another commercially-owned facility anywhere in the state. It hasn’t budged from the health committee since March.
Another sad death: Umberg’s SB 43, which would have tackled body brokering — i.e., selling patients to facilities — by requiring referral agencies to get a certificate of compliance from the Department of Justice, the folks who actually enforce laws. Clever, right? It was held in committee and hasn’t budged since May.
Bigger headwinds
Here’s an idea: raise the bar for outpatient treatment, where most treatment happens. AB 425 by Davies aims to just that.
Right now, licensed residential (i.e., live-in) programs must embrace American Society of Addiction Medicine-esque treatment criteria as a minimum standard of care (a huge upgrade from the almost-nothing required before). But outpatient programs can do still pretty much whatever they like (in an extremely bizarre move, the governor vetoed a bill requiring outpatient facilities to be licensed, but that’s another sad story). Davies’ bill would require outpatient programs to at least adopt ASAM-style standards of care by 2027, but it was referred to the dreaded suspense file in May. “Patients should be getting evidence-based treatment, rather than who-knows-what in some of these places,” Davies said when it was introduced. Ya think?
Then there’s Davies’ AB 423, originally aimed to keep rehab dropouts off the streets by requiring facilities to create discharge and continuing care plans for clients and ensure they can get back home. The idea morphed into a sober home bill, requiring business-operated recovery residences to register their locations with the state Department of Health Care Services. It hasn’t budged from the health committee since April.
AB 877, by Dixon, would direct state health agencies to notify health insurers that addiction treatment in licensed or unlicensed residential facilities is primarily nonmedical, with rare exceptions, and should be billed accordingly. Of course, they should know this, but many insured patients do not. The bill hasn’t budged from the health committee since April. Why is this hard?
AB 448, by Assemblymember Darshana Patel, D-San Diego, would have required the parent or guardian of an underage kid in a California treatment program to be physically in the state for the duration of that treatment. It has morphed into a bill about hospital loan repayment.
Headwinds can be disheartening, but lawmakers don’t easily give up.
“In speaking with the Assembly Health Committee Chair, I decided to make AB 3 and AB 877 two-year bills in order to address and resolve the Chair’s concerns that the legislation may unintentionally create a barrier for those seeking treatment,” Dixon said by email.
“I plan to continue to work with the Chair over the coming months and move forward with both pieces of legislation next year.
“In good news, AB 1356 is still moving through the legislative process and if things go as expected, should be on the Governor’s desk for his consideration by the end of next week.”
Officials at DHCS have told the League of Cities that “significant internal changes” are coming next month in response to the critical audit.
“We’re hoping to hold feet to that fire,” Grinder said.
As are we.