[CA Senate Bill 1101] Will Licensure of Substance Abuse Counselors Improve Quality in Addiction Treatment Services?

Written by Victoria Hinchly

"With no license for addiction counselors in California, we have seen a steady stream of bright and talented people leave for greener pastures." 

In February SB1101 was proposed in CA to create a license for independent practitioners and establish a career path for the professional addiction counselors throughout the continuum of care. The legislation is designed to protect clients while building the workforce in CA, however will professionalization of substance abuse counselors improve the quality of addiction treatment services or lead to increased bureaucracy and higher costs?

Increased attention to the widespread problem of addiction in the United States is a positive thing for the treatment community.  It has led to the expanded availability of insurance coverage that increases access to care; greater awareness of previously hidden public health risks, such as prescription medication abuse; and an expansion in clinical research to understand and treat addiction more effectively.  

All of this attention has also put a spotlight on the personnel who “power” the treatment industry.   In contrast to other parts of the healthcare landscape, where licensure requirements are widespread, the addiction treatment industry in some states lacks consistent qualifications and standards.  Some critics have identified this as an impediment to improving the quality of care.  At its worst, the lack of established standards has led to situations where unqualified counselors, themselves only recently sober, administer incompetent care resulting in relapse for clients they seek to counsel.  While abusive practices may only occur infrequently, they raise broader questions about who is taking care of people with substance use disorders in residential treatment and outpatient programs.  What are their qualifications and training?  Is there a quality problem in the ranks of addiction treatment personnel?

California is making progress toward becoming the 33rd state to license addiction counselors. In February a new proposed law, California Senate Bill (SB) 1101 was introduced to create a license for alcohol drug counselors.   SB 1101 seeks to create a license for independent practitioners and establish a career path for the professionalization of addiction counselors throughout the continuum of care.  The legislation is designed to protect clients while building the workforce in California. Sponsored by California State Senator Bob Weickowski and the California Consortium of Addiction Programs and Professionals, the California Association for Alcohol and Drug Educators, and the California Association of DUI Treatment Programs, SB 1101 builds upon the state’s private certification system by creating an optional license at the top of the career ladder. Certified counselors who choose not to license could continue to work in the state. After a brief “test-in” period the new framework for obtaining licensure would require completing an approved master’s degree.

The Need for Licensing in California
The drive to professionalize counseling services in California is fueled by the state’s recent expansion of its private and public insurance systems to provide addiction treatment. Covered California, California’s implementation of the Affordable Care Act, requires that these services be provided to the insured population, at parity with services provided for all other health conditions. The lack of qualified treatment professionals has left the state in a lurch – offering the expanded benefit, but unable to staff up for the expansion.

“CCAPP has predicted this shortage from the moment SUD services were made a basic benefit for the program,” said CCAPP CEO, Pete Nielsen. “With no license for addiction counselors in California, we have seen a steady stream of bright and talented people leave for greener pastures.”

In addition to the state’s ever growing need for qualified counselors, the profession still contends with a number of high profile cases that suggest inconsistent standards across the state are damaging public perception of the profession, as well as public safety.  For example, authorities are currently investigating several reports of sexual impropriety and illicit drug supply alleged by clients who sought treatment at a number of substance abuse rehabilitation centers in Southern California. 
 
Similarly, public confidence in drug treatment clinics has been undermined by reports of fraud.  In another recent case, involving the now‐defunct Long Beach‐based Atlantic Recovery Group, following an investigation by federal agents, twelve employees, including counseling staff, pleaded guilty to falsely billing the state Medi‐Cal program for over $50 million counseling services that were never provided, in some cases, arranging treatment for teenagers who did not even have drug addiction problems.  While these high‐profile cases may be one of the factors driving the proposed legislation, interest in an increased level of proposed oversight also reflects growing acknowledgment of addiction as a serious, complex and increasingly pervasive disease, which requires a workforce of highly trained and specialist clinicians.  For this reason, many applaud the possibility of counselors joining the ranks of other “licensed professionals,” as signaling a vote of confidence in the important work that they do.  Indeed, if the State of California implements a license for addiction counselors, it will follow the lead of the 32 other states which already have licensing provision.
 
Quality, Cost, Entry and Access
Arguments against efforts to establish more consistent credentials usually focus on anti‐competitive aspects of professionalization, such as the risk of monopolies and barriers to entry.  However, supporters have been quick to assure that licensing will be voluntary and that the intent behind the legislation is to preserve a career trajectory for those – often recovered addicts themselves – who wish to complete their education as they work, aiming for certification first, before ultimately becoming licensed.  By making licensing voluntary, the proposals avoid the risk of restricting the labor pool or limiting the capacity of rehabilitation facilities to offer treatment. 
 
Others have objected that licensing will lead to increased bureaucracy and higher costs.  However, these risks are mitigated by the existing relationships between the California Department for Healthcare Services and the certifying organizations within the state, which should make implementation of the new rules relatively simple and cost effective.  

Will Licensing Be an Effective Driver of Quality?
One of the primary foreseeable changes is that the state will be in a stronger position to sanction individuals who fail to maintain their ‘good standing’ as licensed practitioners by delivering high quality services to their vulnerable clients.  According to a 2015 White House report which examined the effects of licensing on quality, licensing does not necessarily act as a quality driver unless it is supported by robust regulatory oversight.  Diligent monitoring by the licensing body will be crucial to realizing needed quality improvement.  Furthermore, if standards are to continue to improve, consumers will need to be informed that they, too, have a role to play in reporting any poor practice by a licensed counseling professional, while also pointing out where their support needs have been surpassed in order that good examples of counseling practice can be recognized and replicated.  In this way, a culture of quality assurance is more likely to become entrenched.

SB  1101 is currently held in suspense by the Senate Appropriations Committee for lack of funding. Without support from legislative leadership at the Capitol, the bill will need to be reintroduced in 2017 as a new piece of legislation. Counselors, policy makers and treatment advocates have coalesced around the bill’s approach to licensure and are awaiting the administration and legislature’s response.

“Professional licensing standards in addiction treatment are a  logical progression in the development of the industry,” commented Harry Nelson, Managing Partner of healthcare law firm Nelson Hardiman. “By establishing a framework that defines and reinforces professionalism, licensure legislation will benefit not only counselors, but more critically, patients and their families in identifying reliable people and places from whom to seek help.”

To find out how you can support SB 1101, visit CCAPP's legislative page.

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