California substance abusers are gaining more access to affordable health care in the state. What was previously a complex and frustrating system state-wide is being reconstructed from the county level to get local stakeholders more involved.
California renewed an 1115 federal waiver to implement Medi-Cal 2020 last year. Under the waiver and a $90 million grant over the next two years, counties will act as operators of a managed care plan system, allowing more access to care for Medicaid recipients and resources for doctors to become trained for medically assisted treatment (MAT) programs. Healthcare professionals said it’s imperative to create more access, but are fearful federal changes may affect health coverage for substance abusers and Medicaid patients in the future.
California, which expanded Medicaid under the ACA to include 3,824,774 more residents, is adopting the Vermont Hub and Spoke model to combat the opioid epidemic. This model is an intertwining of existing practices to treat people from a regional level in a state that has more substance abuse treatment centers than any other state. Stakeholders, like providers, state healthcare officials, doctors and substance users say there aren’t enough. Of the licensed narcotic treatment programs in California, most are located in Los Angeles County.
The map above shows which California counties have implemented substance abuse treatment plans. (Map by Olivia Lewis for Direct Relief)
Marlies Perez, chief of substance use disorder and compliance for the California Department of Health Care Services, said the previous system was also difficult to navigate. Some treatment centers were at capacity or were too expensive for people seeking help. Potential patients who aren’t immediately served rarely return once the practice has vacancies.
“For someone ready to seek help, we need to get them quickly,” Perez said. “So, if it’s not organized they may get frustrated and say ‘Forget it, I changed my mind’.”
Santa Barbara County, where Direct Relief is based, submitted a plan and has been approved by the state. The 64-page document includes an explanation of the county’s collaborative process, current service gaps and a referral program.
“I think everybody that can get involved in this endeavor should,” said Dr. Charles Fenzi of the Santa Barbara Neighborhood Clinic. “It’s going to be important.”
Though somewhat controversial, doctors are being encouraged to register patients for MAT programs. Through a Pfizer donation, Direct Relief distributed more than 70,000 doses of the opioid overdose reversal drug, naloxone, across the country, including to MAT supporters. The Santa Barbara Neighborhood Clinics are one organization to receive the donation.
Fenzi is one of two doctors in the Santa Barbara Neighborhood Clinic organization certified to treat substance use disorder with suboxone (a mild opioid that alleviates the pain from withdrawal). There are over 1,100 substance abuse treatment centers in California, and less than 200 are licensed narcotic treatment programs.
The Goleta location of the Santa Barbara Neighborhood Clinics is one of them.
Perez said the practice of treating opioid addiction with a less severe opioid is controversial, because it’s stigmatized. Healthcare professionals who are against the practice of giving substance abusers pills to control their addiction prefer a 12-step abstinence model, which Fenzi says have proven to be most successful for alcoholism — not substance abuse. He also knows doctors who are against MAT programs.
“They feel like it’s cheating,” Fenzi said.
The doctor hopes more clinicians will take the MAT certification to offer the service, specifically psychiatrists.
“Drug abuse and opioid use syndrome is a very complicated disease, because it changes the brain and people are dying from it,” Fenzi said. “That’s part of our community, and if we are going to have a healthy community, we have to provide for all segments.”
Aegis Treatment Centers, LLC, is the largest substance use disorder organization in California with 31 clinics across the state. The organization is a proud proponent of MAT programming, although patient retention is low.
The program requires daily methadone treatment and counseling. State regulation says patients can take home up to 28 days-worth of methadone pills before having to go back to the doctor. This treatment method can last months or years. The timeline is dependent upon the patient’s intensity with abuse.
“We have to get them into medication assisted treatment,” said Matthew Adelman, an Aegis representative. “And have it be at an earlier stage in the addiction timeline.”
Aegis also accepts Medicaid patients, while many other programs do not. Over 50 percent of the company’s patients are registered for Medi-Cal.
With threats from the federal government to diminish Medicaid, healthcare experts like Naderah Pourat at University of California, Los Angeles, said states may have to tighten their budgets. She said it could be a “really big blow to a state like California.”
“The state has to decide can they take on these additional 1 million people,” Pourat said.
The UCLA expert said there was “tremendous outreach” to enroll about 1.5 million low-income individuals in California’s Medicaid program.
Clinics like Fenzi’s are required to take anyone who walks into their office. The thought of financial cuts to the Medicaid program are troublesome.
“I can expect financial hardship (for patients), should that pass,” Fenzi said. “The proposed removal of essential health benefits is very concerning to us as well.”
For now, the state still has grant money to work with, and until future funds are determined, healthcare officials said they are doing their best to reduce the opioid epidemic.
“We don’t have all the answers that’s for sure, but we have made a lot of strides forward,” Perez said. “It’s an exciting time, with a lot of great work being done for Californians that suffer from this disease.”
(Editor’s note: This story is the fourth in a series. Earlier stories can be seen below.)