.&!,r lil Eryan[ingAccesst0 QuafttyOpioif,Adlittion treatmentSeraices since 1984 225 VarickStreet,4rh Floor . New York,NY 10014 . Phone:(212) 566-5555. Fax: (2I2) 3664647 E-mail: [email protected]. wwwaatod.org American Ass0ciati0n J0rthsTrealment of0oioidDelendence. lnc, Botrr-clol l)ir('( t()r's January29,2015 \larl. \\. l)rrr irro \l ll \ l ' r t r i c l tr r I I l a n i c c I l ( a u l l r n a r r .l { . N . . \ l . l ] l l . i'ir:l \ir r' I)iiritltnl NlassirchusclIs Angela Gamer Deputy Director (icorgeL \tlrrros.\l l) \ r ' r , r I r l| r t r ' / ' r r ' r t Lr/rtl Division of StateDemonstrationsand Waivers , . \r i z o n a Center for Medicaid and CHIP Services,CMS \ l r ( l r . r (I l { | - i i Mail StopS2-01-16 / t i t t s t r t r ' t 7500 SecurityBoulevard, I l h o c l c I s l a n d Baltimore, MD 21244-1850 I i r r i rl i t t I ' l c r . l \ l . . \ . )( ( l( lrll \ (.olomdo I i o a r r l N l c r n b c sr r\ labarla \ t t s . t n ( r t s r ' .\ l \ Re: Proposed California Amendment to Bridge to Health Reform Demonstration (No. 11-W-00193/9),Drug Medi-Cal Organized Delivery SystemWaiver (.alilornra J r r s o nh l e t t c r . I ' l r .l ) . (.onltrcli(ul l ) r t t t l\ l r I r r r r t l r l i r . \ 1 . . \ Dear Ms. Garner: l , l or i r i a ( i l o l i i t l l r t r r : r r i . r| .\ l l r r I write on behalf of the American Association for the Treatment of Opioid Dependence,which representsover 950 Opioid TreatmentProgramsthroughout \ l i t re t I t c l t t l the United Statesand Mexico, in additionto representing30 statechapters.One lllirrois l i i r l e \ l r t l r o r t c r .| ( \ \ \ ' of our state chapters is the California Opioid Maintenance Providers (COMP) I r r di a n a and we are unified with COMP's position in opposinga portion of the California I i r r rl i o l r r r l r r r L o r r i s i a n a Bridge to Reform Demonstration(No. ll-W-00193/9) Amendment for Drug llort l lirorrl \l \ Medi-Cal OrganizedDelivery SystemWaiver. (icorgirr . I Nlainc I t n r r i l tr \ l i r r l l t o rr r . \ l \ . This waiver was submitted by the Califomia Department of Health Care Services during November 2014. I am specifically writing with regard to the N lc x i c o I t t t i l i al : i g L r c r r l( , r r i l l e r r \. l . l ) . provision that concemsMedication Assisted Treatmentfor Opioid Addiction, 1\,1ichrgan including the use of the three federally approved medications to treat this I i r i r r r \r l r ( a r r r r l l .\ l \ . . l ) t ) i \ l i s s o u r r disorder (methadone,buprenorphine,and VivitrolArlaltrexone). N,larvland h c r r n c l l r\ t o l l t r , \ l . l ) (herrl(,rurlint l( \\\ Ncvatla \lrirlct I irr:r.ll\. Nl5 Ncu Jerscy l:tlriarrl J llitrin\. \l \ Ntu York \lle!lt \L ltrrt North (.anrlina h t n r t r l l r r r r s r ' . | (\ \ ()hio Kcitlt I lor lrlcltl. \l.l rr ()ltlahonr a . \ t t t t j t t t t t i e s o r t (, . \ l ) ( l ) (l l n \ \ l r i U t i a I t i t h a r d I r o r r r i l l , r I. ( I r r Sorttlr (.:rrolina \ \ . J t t r u t s( o l t t s r r o r l l t . \ l \ .l i'nncsscc l)elrbir'( rorr lcl / Jocl l Lttah \ l i l l i r r t l .l ) . \ \ \ . \ irgirria l:tll.rrcl \. t)lrlingt r \\'ashington. DC l i r i t t r r( r r s s n r l t t Like our state chapter, AATOD opposesthe waiver of beneficiary freedom of choice, statewideness,amount, duration, and scope and reasonablepromptness as proposed in the current waiver amendment application as they relate to Medication Assisted Treatment. In our judgment, if this waiver were to be approved,it will result in limited accessto medically neededopioid addiction treatment services,such as those provided in California's registered Opioid TreatmentProgramsand other approvedopioid treatment serviceproviders. This reduced accessruns counter to federal operating authority and the interests of parity legislation and the ACA. It is not necessaryto include Opioid Treatment Programs in the organized delivery system waiver in order to obtain its primary objectives.AATOD is asking CMS to advise the California Department of Health Care Services to eliminate any reference to the narcotic treatment programs from the proposed waiver. Wrshington l{orr litt lisolt. Nl\\\' N4cnr bcrs-at -1.-arge I l i t l r i r r l l i i l r r r r s i\.1 . \ . I 'Ii AATOD/EUROPAI)t Fowu)irg Or3aniiing PurlnLrsoJ the World Itrderotion Jor thr tutncnt o.fOpioid Dcporrlt'rrcl AATOD and COMP have a longstandingappreciationfor what was achieved in a federal court case (Sobky vs. Smoley: 855 F. Supp. 1123, ll28lE.D. Cal. 1994). This representeda landmark court casewhich preventedmany Califomia counties from continuing their practice of restricting access to Medication Assisted Treatment for opioid addiction. At the time of this case, there were only l8 of 58 different California countiesproviding beneficiarieswith accessto opioid addiction treatment.Basedon the evidenceprovided during the course of the case,the districtjudge, JudgeDavid F. Levi, issueda preliminary injunction at first and then a perrnanentinjunction against California state officials. This judgment has stood the test of time up until the present moment when the California Department of Health Care Servicessubmitted its waiver application to CMS. There will be significant injury dealt to opioid addictedindividuals in need of Medication Assisted Treatment for their diseaseif this waiver is approved. It will reverse the enlightened decision of the district court in the Sobky vs. Smoley case and make such opioid addicted individuals vulnerable once again to county authorities. Based on the history of California and frankly in other statesas well, when the broad requirement to provide such treatment to opioid addicted individuals is withdrawn, people lose accessto care. Based on fifty years of establishedresearch,once such accessto care is denied, rates of comorbid infectious diseases,associatedwith the abuseof opioids, will rise. Such untreated opioid addicted individuals will revert to crime and occupy jail cells rather than treatmentslots in medical treatmentfacilities. In view of the long history of county opposition by various county governments in Califomia and inconsistent and non-evidencebased policies with regard to providing accessto carefor opioid addictedindividuals,history will repeatitself unless the federal government denies the submitted waiver by the California Department of Health Care Services as it relates to Medication Assisted Treatment. As a reminder, the state of California is prohibited by the aforementionedfederal court injunction in denying accessor delaying accessto Opioid Treatment Program servicesto Medi-Cal beneficiaries due to budgetary constraints. The submitted waiver is simply a method of returning to a very negativepart of California's history with regardto restrictingneededaccessto medical care for opioid addicted individuals. In this case, if such a waiver is approved, access to care will be restricted or denied by county authorities, increasing the suffering of the individual and their families and doing no good for the public health and well being. If CMS were to approve the submitted amendment,it will overturn the prior federal court injunction, which was based on the absolute proof of systemic violations of law, which led to incredible hardship on behalf of Medicaid beneficiariesin California. ff There is no need to refer to the stigma that affects opioid addicted individuals and which is used either consciously or not by various county boards of supervisorsand behavioral health administrators,who are simply opposedto the use of medications to treat opioid addiction. That was the basis for the court action in Sobky vs. Smoley. ff I am respectfully but forcefully asking the federal govemment to deny the California waiver, as it relates to Medication Assisted Treatment, which will create serious impediments to the life and well being of opioid addicted individuals. It is anticipated that many counties in Califomia will not have the resouces which are necessary to administer the drug Medi-Cal program, creating delays in treatment, denial of treatment, and inevitably, death to individuals who will not be able to accesscare. In view of the history, there is no reasonto believe that county control over the funding and delivery of Drug Medi-Cal Medication Assisted Treatment to eligible beneficiaries will result in any benefit to the patients who need to end their addiction. Finally, Opioid Treatment Programs should be exempted from the waiver and the federal governmentneedsto be the authority to assert such key principlesof treatment. I am certain that my Califomia basedassociateswill make a forceful argument in opposing this submitted waiver in addition to the points that have been made in this correspondence. Thank you for taking these perspectives i'nto considerationin making your determination. Sincerelyyours, '/' ') ftl C /,,*, Mark W. Parrino / ,/ President CC: MehreenHossain ProjectOfficer Hye Sun Lee Acting AssociateRegional Administrator ffi ryl 0l29l5m