Eryan[ing Access t0 Quaftty Opioif, Adlittion treatment Seraices

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]
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Angela Gamer
Deputy Director
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\ r ' r , r I r l| r t r ' / ' r r ' r t Lr/rtl Division of StateDemonstrationsand Waivers
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I l h o c l c I s l a n d Baltimore,
MD 21244-1850
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Re: Proposed California Amendment to Bridge to Health Reform
Demonstration (No. 11-W-00193/9),Drug Medi-Cal Organized
Delivery SystemWaiver
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Dear Ms. Garner:
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I write on behalf of the American Association for the Treatment of Opioid
Dependence,which representsover 950 Opioid TreatmentProgramsthroughout
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the United Statesand Mexico, in additionto representing30 statechapters.One
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of our state chapters is the California Opioid Maintenance Providers (COMP)
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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
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Medi-Cal OrganizedDelivery SystemWaiver.
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This waiver was submitted by the Califomia Department of Health Care
Services during November 2014. I am specifically writing with regard to the
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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,
including the use of the three federally approved medications to treat this
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i \ l i s s o u r r disorder (methadone,buprenorphine,and VivitrolArlaltrexone).
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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
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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.
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.
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.
ftl C /,,*,
Mark W. Parrino
Hye Sun Lee
Acting AssociateRegional Administrator