Federally funded program credited with helping to deliver opioid-addiction treatment to uninsured

An innovative program to provide free treatment for opioid addiction to uninsured and underinsured patients is helping California make progress in tackling the epidemic. That’s the conclusion of health care providers who hope the effort will continue to grow and benefit from federal dollars.  

The so-called hub-and-spoke system connects opioid-treatment programs (“hubs”) with office-based treatment settings such as primary care or substance abuse clinics (“spokes”), with the goal of expanding access to medications for opioid-use disorders. 

The system has resulted in 395 new practitioners in the state trained to prescribe medication to relieve withdrawal symptoms and psychological cravings for opioids. It also has led to 21,800 new patients starting methadone, buprenorphine or extended-release naltrexone, the three Federal Drug Administration-approved medications for treating opioid addiction, according to the California Department of Health Care Services. 

A study by researchers at UCLA on the initial results of the program found promising growth in the hub-and-spoke network but also noted that “challenges to expanding treatment access remain.” The authors recommended, among other things, more mentoring to give practitioners greater confidence in prescribing medications, and offering more support, training and technical expertise to providers.

The program has benefited from over $250 million in federal grants since 2017 to provide treatment to residents suffering from opioid addiction. The 2020 federal budget allotted an additional $1.5 billion nationally to address the problem, and California should be in line to receive a chunk of the money, though it remains to be seen how much and when.

In 2018, 2,428 Californians died from an opioid overdose, according to state data. The state’s overdose rate (5.8 per 100,000 people) is below the national average (14.9 per 100,000), but it varies considerably among counties, with some rural counties exceeding the national average. For example, Humboldt County had a death rate of 19 per 100,000, according to the first-year evaluation of the project in 2018; the rate in Fresno County was 6.3. 

“What I can tell you is that in California … the state prioritized the money for the uninsured and the underinsured,” said David Kan, a member of the American Society of Addiction Medicine. 

The program in California covers the cost of treatment for patients who are uninsured and not eligible for Medi-Cal, the state’s Medicaid program for low-income families, as well as those whose insurance doesn’t pay for opioid-addiction treatment.

Because of the Medi-Cal expansion under the Affordable Care Act, providers “are finding very few (uninsured) patients in California,” Kan said. At the same time, he said, some undocumented residents in need of addiction treatment “may never show up at all” because they fear exposing their immigration status.

The hub-and-spoke system is modeled after one in Vermont that has been credited with substantially increasing that state’s capacity to treat opioid addiction, according to a 2017 research article published in the Journal of Addiction Medicine. Vermont now has “the highest capacity” for such treatment in the country.  

The program’s goal in California for the first two years was to provide treatment to an estimated 20,000 people across the state, a benchmark that officials say was met. Each selected county has a hub, and those centers aim to treat the most intensive cases. The spokes are centers that can provide methadone treatment to more stable patients. 

Nationally, an estimated 2 million nonelderly adults suffer from opioid addiction, and 18% of them are uninsured, according to a July report by the Kaiser Family Foundation. Among the rest, 38% had Medicaid, 36% had private insurance, and 8% had other means of health care coverage. 

Nearly two-thirds of the administrators across the state taking part in the program reported that it gave them the resources to provide treatment to those who are uninsured or underinsured. 

“A lot of our patients are extremely underserved and low-income,” one administrator told evaluators. “And I think that the grant is just a huge blessing in a lot of ways, because without the opportunity (the patients) probably wouldn’t pursue (treatment).” 

The program has allowed patients to get treatment immediately, without having to wait for their Medi-Cal application to be processed, according to the report. 

“Being on the grant, we don’t have to turn anyone away because they can’t afford to pay for 

(treatment). So they can initiate services, get coordinated with case management, eventually get insurance going. But it doesn’t delay their ability to access treatment,” one provider told evaluators. 

The hub-and-spoke system is part of California’s targeted response to the opioid crisis. Counties with high overdose death rates were selected to take part in the project, which is entirely funded by the federal government.

Counties in the state with treatment centers include Fresno, Riverside, San Bernardino, Los Angeles and Sacramento. 

All hubs, except one, are opioid-treatment programs federally licensed to administer methadone as well as other medication for addiction treatment, according to Gloria Miele, one of the project directors. 

The Department of Health Care Services currently doesn’t track insurance status among the patients it serves but says that the free treatment has led to a rise in the number of patients entering the program.

Carol Sloan, a spokeswoman for the Department of Health Care Services, said the department is trying to build a broader treatment system that covers all substance abuse disorders, including methamphetamine and alcohol, which are among the most abused substances in the state. The federal funding helps with training and technical assistance, among other benefits that state officials hope will continue, even if grant funding disappears, she said. 

California chose to use the funds to target the uninsured and underinsured “because those folks have the hardest time getting treatment,” Miele said. 

Plans offered through Covered California, the state’s health insurance marketplace created under the Affordable Care Act, cover opioid-addiction treatment, but some private insurance plans don’t. And although California expanded Medi-Cal, only low-income individuals qualify. 

“This grant provides funding for that gap of services that many people might experience,” she said. 

Getting more health professionals trained has been one of the project’s biggest accomplishments, Miele added. 

Follow the USC Center for Health Journalism Collaborative series "Uncovered California" here.