BILL ANALYSIS �
SB 570
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Date of Hearing: August 6, 2014
ASSEMBLY COMMITTEE ON APPROPRIATIONS
Mike Gatto, Chair
SB 570 (DeSaulnier) - As Amended: July 2, 2014
Policy Committee: HealthVote:10-2
Business and Professions Vote: 8-5
Urgency: No State Mandated Local Program:
Yes Reimbursable: No
SUMMARY
This bill establishes a licensure board within the Department of
Consumer Affairs to regulate drug and alcohol counselors. Key
provisions of this bill:
1)Authorize appointment of a board and executive officer, and
authorize the board to adopt regulations and standards for
licensure, to take disciplinary action against licensees, and
to conduct other related activities.
2)Require licensure for Licensed Advanced Alcohol and Drug
Counselors (LAADC) and registration for Advanced Alcohol and
Drug Counselor Interns to be issued by January 1, 2017.
3)Establishes scope of practice and title protection for
counselors and interns, and allows a licensed counselor to
maintain an independent alcohol and drug counseling practice.
4)Establish "grandparenting" of current counselors by allowing
individuals who are certified to work in facilities as alcohol
and drug counselors, and meet specified experience and
educational requirements, to receive licenses for independent
practice
5)Establish the Advanced Alcohol and Drug Counselors License Fund
to support licensing and intern registration activities, and
specify revenue collected by the board shall be deposited into
the fund.
6)Establish fees, until the board establishes different fees by
regulation, including, among others:
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a) Initial intern registration and renewal fees,
$75.
b) Written examination fee, $150
c) Initial counselor license and renewal fees,
$155.
7)Authorizes other fees, but prohibits total fees from exceeding
reasonable administrative costs.
8)States startup funds shall be derived, as a loan, from the
reserve of the fund.
FISCAL EFFECT
1)One-time start-up costs exceeding $1 million, including
$120,000 in Information Technology (IT) costs to the BreEZe
licensure system (GF or another state fund; potentially
reimbursable by the Advanced Alcohol and Drug Counselors
License Fund if/when sufficient licensure fee revenue is
generated).
2)Annual costs of $1.3 million, which could eventually be
supported by ongoing licensure fees paid into the Advanced
Alcohol and Drug Counselors License Fund. This estimate assumes
the Board registers about 4,000 licensees initially. For
comparative purposes, this is approximately the number of
Licensed Clinical Social Workers regulated by the Board of
Behavioral Sciences. Funding from licensure fees will likely
not be available for the first year or two of operation, so in
the meantime activities would be supported by GF or another
state fund, which could potentially be reimbursed by the
Advanced Alcohol and Drug Counselors License Fund if/when
sufficient licensure fee revenue is generated.
The number of potential licensees is unknown, but based on
assumptions using workforce data from the U.S. Department of
Labor, there should be around 12,000 substance abuse counselors
working in California in 2016. The sponsor has provided data
indicating there are approximately 10,000 certified counselors,
about 3,300 of whom could potentially meet "grandparenting"
standards, as well as 12,000 additional registered counselors
who may be providing services but do not meet certification
criteria. Other mental health professional types may also wish
to become licensed as LAADC.
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3)Annual costs to the Department of Justice associated with
fingerprinting and background check requirements in the range
of $250,000 (fee-supported special fund), as well as unknown,
potentially significant costs to provide legal representation
on behalf of the Advanced Alcohol and Drug Counselor Licensing
Board (reimbursed from the Advanced Alcohol and Drug Counselors
License Fund).
4)Potential unknown cost pressure to counties for substance use
treatment in the Medi-Cal program over the longer term, by
potentially raising the standards for substance abuse treatment
from certified to licensed personnel (local funds; discussed
further below).
COMMENTS
1)Purpose. This bill establishes a board within DCA to license
AADCs in private practice, who are not currently licensed by
the state. This bill is intended to provide a single,
comprehensive regulatory system that will enhance consumer
protection. This bill is co-sponsored by the California
Association of Alcoholism and Drug Abuse Counselors, one of the
counselor certifying agencies approved by the state, and the
California Association of Addiction Recovery Resources, a
non-profit membership that advocates for social model recovery
programs in California.
2)Background . Substance use counselors advise people who suffer
from alcoholism and drug addiction, providing treatment and
support to help the client recover from addiction or modify
problem behaviors. According to the U.S. Department of Labor,
educational requirements for substance use counselors range
from a high school diploma to a master's degree, depending on
the setting, type of work, state regulations, and level of
responsibility.
3)Current Requirements . In California, there is no license, nor
is there a central registry for substance use counselors. Only
counselors who work in facilities that receive payment through
Medi-Cal are required to be certified or registered through one
of six state-approved certifying agencies. The Department of
Health Care Services (DHCS), which administers the Medi-Cal
program, oversees certified counselors indirectly via oversight
of the certifying entities. This mechanism has been criticized
in recent years for being ineffective and providing
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insufficient consumer protection. For example, a 2013 report
by the California Senate Office of Oversight and Outcomes noted
the state makes no attempt to review counselors' criminal
backgrounds, as well as the existence of loopholes allowing
individuals to be employed in facilities as registered
counselors even if their certification had been revoked by a
different certifying agency. California's certifying agencies
require varying amounts of education and experience, but none
require masters-level training.
With respect to those working in private practice, there is no
distinct state licensure type for substance abuse counselors,
but other licensed masters-level behavioral health
professionals, such as licensed professional clinical
counselors, can provide such services within their scope.
Mental health professionals are regulated by the Board of
Behavioral Sciences within DCA.
4)Substance Use Treatment Services . Substance use is a complex
problem with physical, behavioral, and social dimensions. In
addition to professional counseling and medication, treatment
often includes peer recovery support, including 12-step
programs, supportive housing, and similar treatment modalities
and support services. These services are often delivered by
individuals who are not licensed health care professionals.
The wide range of treatment modalities for substance use, and
the peculiar evolution of the definition of substance use and
its treatment, pose challenges for the design of an optimal
workforce training and regulatory system.
Federal law requires health plans and insurers to provide
mental health and substance use treatment at parity with
medical benefits. State regulators are now implementing these
so-called federal mental health parity requirements, so the
field will likely experience significant changes in coming
years, potentially creating more demand for substance use and
other types of counseling as insurance plans are required to
provide more generous coverage.
To address the changes in business practices and workforce
standards required by substance use parity, and in order to
integrate these services into the mainstream health delivery
system, the Substance Abuse and Mental Health Services
Administration (SAMHSA) of the U.S. Department of Health and
Human Services released a report in September 2011 titled
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"Scopes of Practice & Career Ladder for Substance Use Disorder
Counseling" based on an discussions of an expert panel. The
SAMHSA report identifies a model career ladder for substance
use counseling as follows:
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---------------------------------------------------------------
|Category|Title |Education |Allowable practice |
| | | |setting |
|--------+-----------------+---------------+--------------------|
|Entry |Substance Use |GED/High |Works under |
|level |Disorder |School Diploma |clinical |
| |Technician | |supervision |
|--------+-----------------+---------------+--------------------|
|Category|Associate |Associate's |Works under |
| 1 |Substance Use |degree |clinical |
| |Disorder | |supervision |
| |Counselor | | |
|--------+-----------------+---------------+--------------------|
|Category|Substance Use |Bachelor's |Works under |
| 2 |Disorder |degree |clinical |
| |Counselor | |supervision |
|--------+-----------------+---------------+--------------------|
|Category|Clinical |Masters or |Works under |
| 3 |Substance Use |other post |clinical |
| |Disorder |graduate |supervision; intern |
| |Counselor |degree |level |
|--------+-----------------+---------------+--------------------|
|Category|Independent |Masters or |Licensed to |
| 4 |Clinical |other post |practice |
| |Substance Use |graduate |independently |
| |Disorder |degree | |
| |Counselor/Supervi| | |
| |sor | | |
---------------------------------------------------------------
The state's current certification requirements appear most
similar to a Category 1 counselor.
5)Prior Legislation . Numerous prior bills address this issue; all
failed passage.
a) AB 2007 (Williams) of 2012 established a licensing and
certification system for AADCs to be administered by the
Department of Public Health. This bill was held in Assembly
Health Committee.
b) SB 1203 (DeSaulnier) of 2010 instituted a licensing and
certification structure for AOD counselors by DADP. SB 1203
was held in the Assembly Rules Committee.
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c) SB 707 (DeSaulnier) of 2009, which was substantially
similar to SB 1203 of 2010, was held on the Suspense File of
this committee.
d) AB 239 (DeSaulnier) of 2008 established two categories of
licensed alcoholism and drug abuse counselors for persons
licensed to practice alcoholism and drug abuse counseling
under clinical supervision, and persons licensed to conduct
an independent practice of alcoholism and drug abuse
counseling, and to provide supervision to other counselors,
both to be overseen by BBS. AB 239 was vetoed by Governor
Arnold Schwarzenegger who stated he was directing DADP to
work to craft a uniform standard for counselors.
e) AB 1367 (DeSaulnier) of 2007 would have provided for the
licensing, registration and regulation of Alcoholism and
Drug Abuse Counselors, as defined, by BBS. AB 1367 was held
on the Suspense File of this committee.
f) AB 2571 (Longville) of 2004 would have created the Board
of Alcohol and Other Drugs of Abuse Professionals in DCA and
established requirements for licensure of AOD abuse
counselors. AB 2571 failed passage in the Assembly Health
Committee.
g) AB 1100 (Longville) of 2003 would have enacted the
Alcohol and Drug Abuse Counselors Licensing Law, to be
administered by BBS. AB 1100 was held in the Assembly
Business and Professions Committee.
h) SB 1716 (Vasconcellos) of 2002 would have required BBS to
license and regulate alcohol and drug abuse counselors. SB
1716 was held in the Assembly Business and Professions
Committee.
i) SB 537 (Vasconcellos) of 2001 would have required DCA to
initiate a comprehensive review of the need for licensing
substance abuse counselors. SB 537 was vetoed by Governor
Gray Davis due to cost concerns.
1)Support . This bill is supported by a number of substance use
providers. The sponsors and supporters argue this bill will
enhance consumer protection by regulating currently unregulated
counselors who work outside of licensed facilities, as well as
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delineate scope of practices between currently licensed
professions.
2)Opposition . Licensed mental health professionals oppose this
bill, primarily due to grandparenting provisions. National
Association of Social Workers, California Chapter (NASW)
believes that because this bill was gutted and amended late in
the process, many more discussions need to take place in order
to correct the imperfections in the bill. NASW also believes
only those with a masters' degree should be licensed for
independent practice. The California Association of Marriage
and Family Therapists and California Association for Licensed
Clinical Counselors also oppose this bill unless amended based
on the grandparenting provisions, stating while they recognize
the need to further regulate this profession, before the state
spends significant funds to create this license, the law must
be written in a way to ensure consumer protection. CALPCC
states this bill could grant full licensure and the ability to
practice independently to individuals with only a GED or high
school diploma. The California Psychological Association also
opposes.
The California Association for Alcohol and Drug Educators
(CAADE) and other substance use counselor certifying agencies
oppose the bill, contending the idea of licensing private
practitioners has devolved into a self-serving bill for the
almost exclusive benefit of the sponsors. CAADE points out
this bill is inconsistent with the Model Scope of Practice that
requires a Masters' degree for independent practice. The
California Association of Alcohol and Drug Program Executives
opposes the bill unless amended, seeking changes to the
grandparenting provisions, board composition, and scope of
practice. They also note a professional staff that is fully
licensed would be expensive and not affordable under current
Medi-Cal rates.
3)Staff Comments .
a) Start-up Costs. This bill states start-up funds shall be
derived, as a loan, from the reserve of the Advanced Alcohol
and Drug Counselors License Fund established by the bill.
This appears to be an attempt to avoid the need for a GF
loan in order to fund start-up costs. However, staff will
need to be hired, IT systems need to be built, and costs
incurred before licensure activities take place. Thus,
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there will not be any reserve in the fund available to fund
startup activities unless there is a loan or transfer to the
fund from the GF or another fund, and therefore the
chicken-and-egg problem of start-up costs is not obviated by
language requiring startup funds to be derived from the
reserve of the fund.
b) Ongoing Costs. A stand-alone board that only provides
one level of licensure appears to be cost-inefficient. It
is unclear how many individuals will pursue a stand-alone
license for substance use counseling. If numbers of
licensed counselors are fairly low, the cost per licensee
could be significant. For example, if $1.3 million in costs
were incurred annually for 4,000 licensees, this is a
per-licensee cost of over $300 annually, over three times
the $100 per-licensee cost to the Board of Behavioral
Sciences (BBS). Requiring an existing board with similar
expertise, such as the BBS, to establish this license
appears to offer a more cost-effective solution.
Alternatively, consolidating certification and licensure
functions for all levels of substance use counselor could
offer greater cost and administrative efficiency, as well as
better coordination.
c) Potential Impacts to Medi-Cal. This bill may indirectly
lead to cost pressure to Medi-Cal to raise the standards
from certified to licensed personnel. To the extent
licensure raises the minimum training level and it becomes
the standard of care to utilize only licensed personnel, it
would lead to cost pressure on Medi-Cal to raise standards
and, commensurately, reimbursement. Language in this bill
stating it does not require Medi-Cal to use licensed
personnel is likely inadequate to avoid these potential
impacts, as Medi-Cal generally must provide care that meets
community standards. Substance use treatment for Medi-Cal
has been realigned to counties, so if the standard of care
is raised, it could result in cost pressure to counties.
d) Grandparenting Provisions Allow Independent Practice.
This bill would allow counselors certified by 2018 who meet
experience thresholds (10,000 hours of work, minus 2,000
hours for each higher degree obtained) to gain licensure
without meeting the formal educational requirements
otherwise required for licensure. There is currently no
degree requirement for certified counselors, although for a
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certified counselor to earn a license, this bill would
require the counselor to document a certain number of
educational units in the field and to pass an exam. Thus,
through the grandparenting provision, it appears one could
earn what would normally be a masters-level license that
allows for independent practice without any college degree,
as long as one met the exam and educational unit criteria.
It is unclear whether the level of education required under
the grandparenting provisions offers sufficient preparation
for independent practice. Allowing independent practice
without a masters' degree appears to be inconsistent with
the SAMHSA model career ladder described above.
e) Two-Tier Regulatory System with No Explicit Coordination.
This bill creates a licensure board within DCA, but does not
explicitly direct the board to coordinate with the state's
current certification regulatory structure within DHCS.
There appear to be some areas of alignment between the
requirements, but it is unclear whether the board would
coordinate effectively with DHCS in order to provide an
effective career pathway for substance use counselors.
Since the board would also operate independent from DHCS, it
would essentially create a situation where two different
state regulatory entities, within different agencies of
state government, would be charged with regulating two tiers
of the same profession. In addition, it would not address
purported problems of lax oversight of the certified
workforce under DHCS, since it only requires background
checks and oversight of the workforce applying for licensure
under DCA.
In conclusion, though this bill intends to "provide a
single, comprehensive regulatory system that will enhance
consumer protection," it does not appear to do so.
Analysis Prepared by : Lisa Murawski / APPR. / (916) 319-2081