[House Hearing, 108 Congress]
[From the U.S. Government Publishing Office]



 
                        RECOVERY NOW INITIATIVE

=======================================================================

                                HEARING

                               before the

                   SUBCOMMITTEE ON CRIMINAL JUSTICE,
                    DRUG POLICY AND HUMAN RESOURCES

                                 of the

                              COMMITTEE ON
                           GOVERNMENT REFORM

                        HOUSE OF REPRESENTATIVES

                      ONE HUNDRED EIGHTH CONGRESS

                             FIRST SESSION

                               __________

                           FEBRUARY 27, 2003

                               __________

                            Serial No. 108-7

                               __________

       Printed for the use of the Committee on Government Reform


  Available via the World Wide Web: http://www.gpo.gov/congress/house
                      http://www.house.gov/reform

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                           WASHINGTON : 2003
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                     COMMITTEE ON GOVERNMENT REFORM

                     TOM DAVIS, Virginia, Chairman
DAN BURTON, Indiana                  HENRY A. WAXMAN, California
CHRISTOPHER SHAYS, Connecticut       TOM LANTOS, California
ILEANA ROS-LEHTINEN, Florida         MAJOR R. OWENS, New York
JOHN M. McHUGH, New York             EDOLPHUS TOWNS, New York
JOHN L. MICA, Florida                PAUL E. KANJORSKI, Pennsylvania
MARK E. SOUDER, Indiana              CAROLYN B. MALONEY, New York
STEVEN C. LaTOURETTE, Ohio           ELIJAH E. CUMMINGS, Maryland
DOUG OSE, California                 DENNIS J. KUCINICH, Ohio
RON LEWIS, Kentucky                  DANNY K. DAVIS, Illinois
JO ANN DAVIS, Virginia               JOHN F. TIERNEY, Massachusetts
TODD RUSSELL PLATTS, Pennsylvania    WM. LACY CLAY, Missouri
CHRIS CANNON, Utah                   DIANE E. WATSON, California
ADAM H. PUTNAM, Florida              STEPHEN F. LYNCH, Massachusetts
EDWARD L. SCHROCK, Virginia          CHRIS VAN HOLLEN, Maryland
JOHN J. DUNCAN, Jr., Tennessee       LINDA T. SANCHEZ, California
JOHN SULLIVAN, Oklahoma              C.A. ``DUTCH'' RUPPERSBERGER, 
NATHAN DEAL, Georgia                     Maryland
CANDICE S. MILLER, Michigan          ELEANOR HOLMES NORTON, District of 
TIM MURPHY, Pennsylvania                 Columbia
MICHAEL R. TURNER, Ohio              JIM COOPER, Tennessee
JOHN R. CARTER, Texas                CHRIS BELL, Texas
WILLIAM J. JANKLOW, South Dakota                 ------
MARSHA BLACKBURN, Tennessee          BERNARD SANDERS, Vermont 
                                         (Independent)

                       Peter Sirh, Staff Director
                 Melissa Wojciak, Deputy Staff Director
              Randy Kaplan, Senior Counsel/Parliamentarian
                       Teresa Austin, Chief Clerk
              Philip M. Schiliro, Minority Staff Director

   Subcommittee on Criminal Justice, Drug Policy and Human Resources

                   MARK E. SOUDER, Indiana, Chairman
NATHAN DEAL, Georgia                 ELIJAH E. CUMMINGS, Maryland
JOHN M. McHUGH, New York             DANNY K. DAVIS, Illinois
JOHN L. MICA, Florida                WM. LACY CLAY, Missouri
DOUG OSE, California                 LINDA T. SANCHEZ, California
JO ANN DAVIS, Virginia               C.A. ``DUTCH'' RUPPERSBERGER, 
EDWARD L. SCHROCK, Virginia              Maryland
JOHN R. CARTER, Texas                ELEANOR HOLMES NORTON, District of 
MARSHA BLACKBURN, Tennessee              Columbia
                                     CHRIS BELL, Texas

                               Ex Officio

TOM DAVIS, Virginia                  HENRY A. WAXMAN, California
                   Christopher Donesa, Staff Director
              Nicholas Coleman, Professional Staff Member
                         Nicole Garrett, Clerk
                  Julian A. Haywood, Minority Counsel

                            C O N T E N T S

                              ----------                              
                                                                   Page
Hearing held on February 27, 2003................................     1
Statement of:
    Boyer-Patrick, Jude, M.D., M.P.H., Hagerstown, MD............    67
    Walters, John P., Director, Office of National Drug Control 
      Policy, accompanied by Andrea Barthwell, Deputy Director 
      for Demand Reduction, Office of National Drug Control 
      Policy; and Charles G. Curie, Administrator, Substance 
      Abuse and Mental Health Services Administration............    23
Letters, statements, etc., submitted for the record by:
    Boyer-Patrick, Jude, M.D., M.P.H., Hagerstown, MD, prepared 
      statement of...............................................    70
    Clay, Hon. Wm. Lacy, a Representative in Congress from the 
      State of Missouri, prepared statement of...................    22
    Cummings, Hon. Elijah E., a Representative in Congress from 
      the State of Maryland, prepared statement of...............     8
    Curie, Charles G., Administrator, Substance Abuse and Mental 
      Health Services Administration, prepared statement of......    40
    Davis, Hon. Thomas M., a Representative in Congress from the 
      State of Virginia, prepared statement of...................    16
    Ose, Hon. Doug, a Representative in Congress from the State 
      of California, prepared statement of.......................    83
    Ruppersberger, Hon. C.A. Dutch, a Representative in Congress 
      from the State of Maryland, prepared statement of..........    85
    Souder, Hon. Mark E., a Representative in Congress from the 
      State of Indiana, prepared statement of....................     3
    Walters, John P., Director, Office of National Drug Control 
      Policy, prepared statement of..............................    28

                        RECOVERY NOW INITIATIVE

                              ----------                              


                      THURSDAY, FEBRUARY 27, 2003

                  House of Representatives,
 Subcommittee on Criminal Justice, Drug Policy and 
                                   Human Resources,
                            Committee on Government Reform,
                                                    Washington, DC.
    The subcommittee met, pursuant to notice, at 10:07 a.m., in 
room 2154, Rayburn House Office Building, Hon. Mark E. Souder 
(chairman of the subcommittee) presiding.
    Present: Representatives Souder, Davis of Virginia, Mica, 
Blackburn, Cummings, Davis of Illinois, Bell and Ruppersberger.
    Staff present: Christopher Donesa, staff director and chief 
counsel; Nicholas Coleman and Elizabeth Meyer, professional 
staff members; John Stanton, congressional fellow; Nicole 
Garrett, clerk; Julian A. Haywood, minority counsel; Earley 
Green, minority chief clerk; and Teresa Coufal, minority 
assistant clerk.
    Mr. Souder. Good morning, and welcome to all of you for the 
session's first meeting of the 108th Congress. We have a full 
agenda for this session, and I'm very much looking forward to 
the opportunity to continue working on it with our 
distinguished ranking member, the gentleman from Maryland, Mr. 
Cummings.
    I would also like to welcome Chairman Tom Davis of the full 
committee to our hearing today and to thank him publicly for 
the strong personal interest and support he has demonstrated 
for the work of this subcommittee.
    I would finally like to thank and specially recognize our 
new vice chair, the gentleman from Georgia, Mr. Deal and all of 
the new Members on both sides of the aisle.
    The subcommittee will be most intensely focused in the 
beginning of this Congress on the reauthorizing legislation for 
the Office of National Drug Control Policy and its programs. 
Next week we will begin a series of hearings on that 
legislation. Our topic for today, however, is so important that 
I thought it should be the natural first meeting for the 
subcommittee.
    Today's hearing will consider the significant new drug 
treatment initiative announced by President Bush in his State 
of the Union Address. Drug treatment, specifically getting 
treatment resources where they are needed, is one of the 
cornerstones of our national drug control policy and strategy 
and must be a prominent part of any sensible drug policy.
    The necessary emphasis on law enforcement and homeland 
security issues during the last Congress prevented the 
subcommittee from addressing treatment issues to the extent 
they deserved. So I particularly wanted to begin with treatment 
at the center of our agenda today.
    The President's initiative is a substantial, innovative and 
compassionate step forward. I commend his personal interest and 
support in emphasizing drug treatment as a priority item in his 
domestic agenda. His proposal will take a big step forward to 
make drug treatment fully available in the United States. 
Perhaps just as importantly, however, it will also break new 
ground by taking steps toward greater availability, 
accountability and innovation in the treatment choices 
available to help addicted Americans get well.
    The President's initiative would provide $600 million over 
the next 3 years to supplement existing treatment programs. 
That amount of money is intended to pay for drug treatment for 
most Americans who now want it but can't get it, many of whom 
can't afford the cost of treatment and don't have the insurance 
that covers it. It could help up to 100,000 more users get 
treatment. The program also has enormous potential to open up 
Federal assistance to a much broader range of treatment 
providers than are used today.
    Through the use of vouchers the initiative will support and 
encourage variety and choice in treatment and could open up and 
support a significant number of new options for drug users to 
get treatment. Finally, the emphasis on accountability should 
help us make significant progress in the most difficult issues 
of drug treatment policy, finding and encouraging programs that 
truly work to help and heal the addicted as well as ensuring a 
meaningful and effective return on taxpayer dollars spent on 
treatment.
    I am pleased to welcome today's excellent witnesses for the 
first public hearing and detailed discussion of this important 
Presidential initiative. From the Office of National Drug 
Control Policy we are joined by Director John Walters, who has 
enthusiastically and energetically worked to outline and 
develop the program. From the Substance Abuse and Mental Health 
Services Administration, we are joined by the Administrator, my 
fellow Hoosier, Charles Curie. Thank you both for your 
leadership. We will later be joined by Dr. Jude Boyer-Patrick, 
who has been a leading treatment professional in the State of 
Maryland, to receive her insights.
    It is a real pleasure to have all of you here today, and 
the subcommittee looks forward to discussing the initiative 
with you in depth.
    [The prepared statement of Hon. Mark E. Souder follows:]
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    [GRAPHIC] [TIFF OMITTED] T6828.002
    
    Mr. Souder. I now yield to the ranking member, Mr. 
Cummings.
    Mr. Cummings. Thank you very much, Mr. Chairman. I am very 
pleased that we are holding this hearing today. I'm glad that 
the administration is taking a closer look and putting a 
greater emphasis on treatment. Treatment is something that I 
have preached about since I came here some 6\1/2\ years ago.
    But before I go into my official statement Mr. Chairman, 
I'd like to welcome to our subcommittee, Chris Bell from Texas, 
Linda Sanchez from California, and certainly Dutch 
Ruppersberger, my Maryland colleague, who has worked with me 
prior to coming to the Congress in so many drug issues in the 
Baltimore area, and our districts literally are connected to 
each other. So I welcome him. I know that he will be a 
tremendous asset to our committee.
    Let me just say a few things right here. Mr. Chairman, 
there is no simple issue that is more important to me than the 
issue of drug treatment. Baltimore City, the city I represent 
in Congress, has been devastated by recent epidemics of crack 
cocaine and heroin addiction. There are some 65,000 people in 
Baltimore addicted to illegal drugs, roughly a tenth of the 
city's population, and these people desperately need treatment, 
and effective treatment.
    It is interesting to note while I applaud the President's 
effort with regard to treatment, and I think it is absolutely 
wonderful, I must tell you that when I returned to my district 
the day after and talked--after the State of the Union and 
folks were talking about the program in Baltimore, we saw it 
from a whole different perspective. When the President talked 
about helping 300,000 people, the people in my district said, 
well, we've got 65,000 right in 1 of 435 districts--we've got 
65,000 just in our district. And so that is not necessarily a 
criticism, because one thing that I must say is the drug czar 
are--Walters is making a study, marching toward the right 
direction as opposed to staying still or going backward, and I 
do appreciate that. I want to make that real clear, but I want 
to put this in context, too.
    Last year, Mr. Chairman, you convened a field hearing in 
Baltimore at my request, and we heard testimony concerning the 
results of a ground-breaking study entitled Steps to Success: 
The Baltimore Drug and Alcohol Treatment Outcome Study. 
Commissioned by the Baltimore Substance Abuse Systems, Inc., 
and conducted by the University of Maryland, Johns Hopkins 
University and Morgan State University, the study examined 
nearly 1,000 treatment participants in 16 licensed, publicly 
funded treatment programs. The findings indicate a marked 
reduction in drug and alcohol use, criminal conduct, risky 
health behaviors and depression among individuals who 
voluntarily entered publicly funded outpatient drug and alcohol 
treatment programs in Baltimore City.
    In the judgment of the Baltimore City Health Commissioner 
Peter Beilenson, Steps to Success proved conclusively that drug 
treatment is effective in Baltimore City. The study remains the 
largest, most comprehensive and most thoroughly documented 
study of its kind to focus on a single city. The Baltimore 
study's findings reinforce those of other drug treatment 
studies, including a report by the Institute of Medicine which 
found that, ``an extended abstinence, even if punctuated by 
slips and short relapses, is beneficial in itself and may serve 
as a critical intermediate step toward lifetime abstinence and 
recovery.''
    In announcing the National Drug Control Strategy and drug 
control budget last year, President Bush and the Office of 
National Drug Control Policy Director John Walters expressed a 
strong commitment to, ``healing American's drug users,'' 
pledging an additional $1.6 billion in drug treatment funding 
over 5 years.
    For this the administration received high praise from 
treatment experts and advocates, and deservedly so. There has 
not always been strong bipartisan support for funding drug 
treatment. It seems, thankfully, that we are finally beyond 
questioning the value of treatment and firmly on the road to 
funding recovery. The question that remains is how 
aggressively, and what is the most effective and efficient 
means of reaching people in need.
    In his recent State of the Union Address, President Bush 
proposed a new drug treatment initiative called Recovery Now to 
be funded with $600 million over the next 3 years. The 
proposal's reliance on State-issued vouchers is a sharp 
departure from the way the Federal Government has funded drug 
treatment through the Substance Abuse and Mental Health 
Services Administration since SAMHSA's creation in 1992. For 10 
years the vast majority of Federal funding for drug treatment 
has been allocated to States by way of a population-based 
formula under the substance abuse prevention and treatment 
block grant.
    This year the drug treatment system is undergoing 
significant change as the block grant transitions to a 
performance partnership grant. This change is already altering 
the relationship between the States and SAMHSA, with a goal of 
providing greater flexibility to States in exchange for greater 
accountability.
    Among other changes, States are in the process of upgrading 
their computer systems in order to collect and convey 
additional data on program performance, and I applaud that.
    Like the existing Targeted Capacity Expansion Grant 
designed to help States respond quickly to emerging treatment 
needs, Recovery Now will operate parallel to the substance 
abuse partnership performance grant. The initiative will 
require Governors to submit proposals for State-run voucher 
systems that will operate subject to Federal guidelines that 
are presently under development. A request for applications 
will issue later this year.
    As we will hear from the administration witnesses, Director 
Walters, SAMHSA Administrator, Charles Curie, Recovery Now is 
intended to give people in need of drug treatment a broader 
array of treatment options by expanding the network of 
providers who will be eligible to receive Federal funding for 
providing treatment services. As we all observed, the President 
took pains in his State of the Union Address to emphasize that 
pervasively sectarian faith-based organizations would be part 
of the expanded provider network. The standards to which these 
groups will be subject is an important issue for Members like 
myself who are deeply concerned about the implications 
permitting the use of Federal funds by programs that would 
discriminate on the basis of religion against employees or 
people seeking treatment or both. I have often said that we 
cannot allow our tax dollars to be used to discriminate against 
us.
    The Recovery Now initiative is also designed to increase 
provider accountability by making reimbursement to providers 
contingent upon their demonstrated effectiveness, determined 
according to a set of evidence-based outcome measures. I agree 
with that. I think that is very good. This is a novel approach 
in the public health field. It aims to create healthy 
competition among providers to deliver the most effective 
treatment.
    As we explore all of this new ground, I'm delighted that 
we'll have the outside perspective of an experienced medical 
practitioner and researcher in the field of child and 
adolescent mental health and substance abuse. Dr. Jude Boyer-
Patrick of Brooklane Health Services in Hagerstown, MD, is a 
woman of deep faith, an addition in mental health specialists, 
and a shaper of public policy through her service on Maryland's 
Drug and Alcohol Council and the Maryland Drug Treatment Task 
Force. She will offer her informed insight concerning a variety 
of outstanding concerns relating to Recovery Now, including how 
State standards for care, licensing and certification will fare 
under the proposal, State administrative costs and possible 
obstacles to implementation, standards that will be applicable 
to faith-based treatment providers, challenges to providers 
posed by the voucher reimbursement system, protecting the 
existing substance abuse grant from erosion, and ensuring the 
maximum participation by the States under initiative--under the 
initiative's competitive grant structure.
    And I'm also pleased, too, that Dr. Andrea Barthwell, the 
Deputy Director for Demand Reduction, is with us today. She, 
working with the drug czar--that has been most cooperative with 
our office. And let me finally say this, too, to the drug czar, 
Mr. Chairman. The drug czar has been extremely responsive to 
the needs of the Seventh Congressional District of Maryland. He 
has paid several visits to our district already. He attended 
the funeral of seven people--of six people and then seven. 
There was a seventh later on--who died as a result of a fire, 
where drug salespersons fire-bombed a house and literally 
burned up six members of this household who had been 
cooperating with police. And later--it was a mother and five 
children--he attended that funeral and made one of the most 
moving comments that I have ever heard in my life by anybody on 
anything.
    He has been there for us, and he has worked very closely 
with us trying to bring some remedies in a short period of time 
to our district, and so I do applaud you, drug czar. I always 
call you the drug czar. I'm trying to fix it up so it sounds 
real nice in public, but I thank you.
    And so, Mr. Chairman, again, I am glad that we're holding 
this hearing. I think that this is a step in the right 
direction, and I also want to thank Chairman Davis for his 
interest in this issue. And I think just having him as the 
chairman of our overall committee heightens the visibility and 
the opportunities that we will have to explore all of these new 
issues and new programs so that, again, we can use our tax 
dollars in a most effective and efficient manner.
    [The prepared statement of Hon. Elijah E. Cummings 
follows:]
[GRAPHIC] [TIFF OMITTED] T6828.003

[GRAPHIC] [TIFF OMITTED] T6828.004

[GRAPHIC] [TIFF OMITTED] T6828.005

[GRAPHIC] [TIFF OMITTED] T6828.006

[GRAPHIC] [TIFF OMITTED] T6828.007

[GRAPHIC] [TIFF OMITTED] T6828.008

    Mr. Souder. Now I'd like to yield to the chairman of the 
full Government Reform Committee, Mr. Tom Davis of Virginia.
    Mr. Davis of Virginia. Mr. Souder, thank you, and thank you 
for holding your hearings and your leadership. And I thank my 
friend from Maryland for his comments and for his leadership on 
this issue as well.
    This is not a partisan issue at all. This affects people, 
Republicans, Democrats, inner city, wealthy, suburbs, rural 
areas. It is a tremendous responsibility for this committee and 
for the drug czar, for lack of a better title, to undertake, 
and we want to give you the tools.
    And over the past year drug use among young Americans has 
been on the decline, I think, due in large part to our joint 
administration, congressional--our joint work and our 
substantial drug prevention efforts, but when it comes to 
addressing the complex dilemma of drug addiction, prevention is 
only one part of the equation. Treatment of substance abuse, as 
my friends have said, and addiction is also essential to the 
goal of decreasing the number of users.
    Because addiction has so many dimensions and disrupts 
multiple aspects of an individual's life, treatment is never 
easy. Drug users need a support system of family, friends and 
institutions to help guide them to treatment and recovery.
    I know firsthand the consequences that substance abuse can 
have on a family. My father was a career alcoholic, he actually 
served two tours in the State prison system in Virginia for 
alcohol-related offenses. It is not just the victim. The whole 
family struggles with these issues, and it affects an extended 
family as well.
    The President's 2003 National Drug Control Strategy 
highlights the importance of healing America's drug users and 
getting treatment resources where they are needed most. I 
appreciate John Walters and Charlie Curie of the Substance 
Abuse and Mental Health Services Administration for being here 
this morning to discuss the President's drug treatment 
initiative, an important outside-the-box element of the 
President's strategy.
    According to the Office of National Drug Control Policy, 
roughly 6 million Americans are in need of drug treatment, but 
a large number of these users fail to recognize their need for 
treatment or don't have access to treatment programs. So the 
administration has proposed a significant increase in drug 
treatment funding that will expand access to substance abuse 
treatment in communities across America.
    The new treatment program would devote $600 million over 3 
years for a new initiative to fight drug addiction. It aims to 
expand access to treatment centers for an estimated 100,000 
alcohol and drug abusers annually through a voucher system that 
will let the government monitor where the dollars are being 
spent. Too many Americans in search of treatment simply cannot 
get it. As proposed, the program would give people vouchers to 
seek drug rehabilitation treatment centers of their choice, 
including community and faith-based treatment organizations.
    Just a note on faith-based organizations. I will never 
forget as a member of the county board in Fairfax having the 
Salvation Army come forward with a drug and alcohol 
rehabilitation center adjacent to some residential 
neighborhoods, and a band of associations came out and fought 
it, but we prevailed. We zoned it. It came in and has over 125 
individuals at a time it can take. And I was there after it was 
built, and I was there the first year when people came up and 
gave testimony for a year without drugs and alcohol. There are 
2- and 3-year pins, and the interesting thing about the faith-
based is they take not just the medical side of it, but they 
look at the heart, they look at the soul to heal the entire 
person.
    These can be successful programs as well. I think sometimes 
we fail to utilize these as well. I'm happy to see that is a 
part of this program, because in many cases that is the answer 
is changing the whole person from the inside.
    As proposed, the program gives people vouchers to seek drug 
rehabilitation treatment centers of their choice. Obviously 
there is much more to this complex proposal than I've outlined. 
I'll leave it up to our witnesses this morning to elaborate on 
that initiative and provide all the details, but with let me 
make a couple more points.
    First, we all know that drugs affect people from all walks 
of life, and addiction does not discriminate. I believe that 
making funding available through the voucher program to a wide 
range of providers, including faith- and community-based 
programs, schools, health care providers, employers and law 
enforcement agencies, better ensures the substance abusers will 
be matched with a treatment program appropriate for them. The 
plan, plain and simple, broadens the network of treatment 
providers.
    Second, there is much about the proposal's details that I 
like on the face. It relies heavily on collaboration with the 
States. It fosters competition among providers. It promises 
flexibility in terms of the systems developing in individual 
States, and it mandates strict oversight of programs to ensure 
their effectiveness.
    Finally, I've just returned from a trip to Colombia with 
Chairman Souder. We'll be going back before long because the 
battle going on there against narcoterrorism is our battle as 
well, but it is clear to me as we continue to wage war on the 
supply side of the drug equation, we need to reaffirm our 
commitment to address the demand side as well.
    Again, Chairman Souder, I thank you for organizing today's 
important hearing to review the President's treatment 
initiative. This will be the first in a series of hearings 
planned to evaluate all of the components of the President's 
2003 drug strategy. I look forward to the input from my 
colleagues on the other side as well. Many of them have worked 
in their own districts on this program, and it is important to 
them as well. And we can work on this in a bipartisan way. I 
think we can come up with a good result. I look forward to 
hearing the testimony this morning from the officials 
responsible for developing and implementing the program. Thank 
you.
    Mr. Souder. I thank the Chairman.
    [The prepared statement of Hon. Thomas M. Davis follows:]
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    Mr. Souder. Before yielding to Mr. Davis, I want to 
elaborate. Both Mr. Cummings and Mr. Davis and I have made--
actually all three of us made references to some of what the 
committee is going to be doing, and as I said, our primary 
focus, because we're trying to move a bill through the full 
committee and the subcommittee in a reasonably expeditious 
manner for the ONDCP reauthorization, we're focusing on more 
particular elements of the national ad campaign, the HIDTAs. 
And so over the next few months, we'll continue our work on the 
borders, which are critical, but part of our oversight.
    In the faith-based component, this subcommittee also has 
oversight over all faith-based programs, not just on the 
treatment, and today we're focusing on treatment in general, 
which would include the vouchers, but not zeroing in on faith-
based, and I appreciate working with the minority. I have made 
a commitment we will have a separate hearing talking about that 
issue alone inside the treatment question, in addition to 
basically 2 years of looking at the range of faith-based. We're 
going to have disagreements on how much government funding and 
which type of government funding should go in, but we're going 
to look at the other parts of the faith-based initiatives as 
well, which would include a much broader program where we may 
have wide agreement, as well as the more narrow controversial 
part, which is when government funds are involved in the 
treatment program.
    And then as far as the tragedy with the Dawson family in 
Baltimore, we've made a commitment that later this spring we'll 
be doing a hearing there to look at how the government should 
be providing protection for those who work with the government 
who are threatened, and they should not be out there to be 
terrorized by the dealers and their networks, and it is a 
broader question in a policy way of how we're trying to protect 
those who are working at the grassroots level. And I definitely 
appreciate the leadership of the ranking member with that.
    With that, I'd like to yield to the long-time acting member 
of this subcommittee Mr. Davis of Illinois if he has any 
opening statement.
    Mr. Davis of Illinois. Thank you very much, Mr. Chairman. 
Let me just, first of all, commend you and the ranking member, 
Mr. Cummings, for the aggressive manner in which you have 
approached the work of this committee. I've been very pleased 
to travel with you to Fort Wayne, IN, for a field hearing, and 
I want to thank you for the hearing which you conducted at my 
request in Chicago.
    I also want to welcome the witnesses. It seems as though 
the seventh number of districts must have some affinity for 
Director Walters, I was pleased to visit with him and with you 
at the Safer Foundation not very long ago where we had a 
tremendous experience.
    I also want to welcome Mr. Curie, and I definitely want to 
welcome my neighbor, my friend and long-time associate Dr. 
Andrea Barthwell, who has had firsthand hands-on experience 
working on the ground with these issues and problems as a 
practitioner with the Human Resources Development Institute and 
other entities. And so, Dr. Barthwell, it is indeed a pleasure 
to see you.
    Very briefly, Mr. Chairman, let me just suggest that this 
hearing is so important, and the work of this committee is so 
important. We all know that much of the crime, much of the 
prison population explosion, many of the problems associated 
with reentry are all associated with drug use and abuse, and so 
when we deal with the issue of reducing the presence of drug 
use and abuse in our society, we're dealing with needs that cut 
across all races, all economic groups all parts of what makes 
this Nation what it is.
    I'm pleased to see that prevention, treatment and reduction 
are all a part of a strategy, and I think all of those 
components must be effectively used.
    We've had some discussion about the utilization of the 
faith-based approach, and as one who is a strong component--
strong proponent, I've seen faith-based programs work, I've 
seen people involved in them. My district has a serious drug 
problem because of its poverty and because of its location and 
because of where it is, Chicago, IL, in the heart of the 
Midwest.
    Programs can work, do work. I would make a strong plea that 
we make every effort to eradicate any possibility of 
discrimination that could possibly exist, and that we let an 
idea that is really a great idea, a tremendous idea, let that 
idea stand on its merits and let it work on its merits by 
taking away any possibility that any person, because of their 
religion, their religious thoughts, their religious beliefs, 
could possibly not acquire the services and the benefits.
    I look forward to discussion, I look forward to development 
and implementation, and, again, I thank you, Mr. Chairman, and 
appreciate all of the witnesses who have come to share.
    Mr. Souder. Thank you, Mr. Davis.
    Mr. Clay, do you have any opening remarks?
    Mr. Clay. Thank you, Mr. Chairman. First I'd like to 
acknowledge your foresight for holding this important debate 
concerning the President's recently announced antidrug 
treatment program, the Recovery Now initiative. America needs 
an effective drug treatment program that will work. Previous 
efforts by law enforcement agencies have already proven that 
drug eradication initiatives alone have not stopped the problem 
of drug adduction, even in the best of scenarios.
    Plain and simple, drug addiction should not be viewed as a 
criminal problem, but rather, it should be perceived as a 
medical challenge. The increase in human drug addiction is a 
societal problem that is a challenge that transcends race, 
class and financial standing.
    The Recovery Now initiative is an ambitious step in the 
right direction to alleviate the challenge of rampant drug 
abuse in the 21st century.
    And, Mr. Chairman, I ask unanimous consent to submit my 
statement into the record.
    Mr. Souder. Without objection, so ordered.
    [The prepared statement of Hon. Wm. Lacy Clay follows:]
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    Mr. Souder. I thank Mr. Clay for being here today, as well 
as Congresswoman Blackburn from Tennessee and Congressman 
Ruppersberger. We'll have many Members in and out this morning, 
and I appreciate the patience of our witnesses.
    Before proceeding, I would like to take care of a couple of 
procedural matters. First, I ask unanimous consent that all 
Members have 5 legislative days to submit written statements 
and questions for the hearing record; that any answers to 
written questions provided by the witnesses also be included in 
the record. Without objection, so ordered.
    Second, I ask unanimous consent that all exhibits, 
documents and other materials referred to by Members or the 
witnesses may be included in the hearing record; that all 
Members be permitted to revise and extend their remarks, and 
without objection, so ordered.
    I would also like to ask the members of the committee and 
the minority in particular, we didn't notice Dr. Andrea 
Barthwell, who is going to be here to support the Director, but 
in case she fields some questions, is it OK if I swear her in 
at this time?
    Mr. Cummings. Yes. I think that is a great idea. I think 
you need a sign, too.
    Mr. Souder. Without objection, we'll include you on the 
first panel, because we didn't notice it in the committee. So 
we need to go through that procedure.
    If each of you could rise and raise your right hands, it is 
the practice of this subcommittee as an oversight committee to 
ask the witnesses to testify under oath. If you'll raise your 
right hands, I'll administer the oath.
    [Witnesses sworn.]
    Mr. Souder. Let the record show that each of the witnesses 
responded in the affirmative.
    We'll now hear from Director Walters. We thank you first 
for your leadership. We very much appreciate that, and I look 
forward to hearing your testimony today.

  STATEMENTS OF JOHN P. WALTERS, DIRECTOR, OFFICE OF NATIONAL 
 DRUG CONTROL POLICY, ACCOMPANIED BY ANDREA BARTHWELL, DEPUTY 
DIRECTOR FOR DEMAND REDUCTION, OFFICE OF NATIONAL DRUG CONTROL 
 POLICY; AND CHARLES G. CURIE, ADMINISTRATOR, SUBSTANCE ABUSE 
           AND MENTAL HEALTH SERVICES ADMINISTRATION

    Mr. Walters. Thank you. I'd like to thank Chairman Davis 
for being here and for the conversations and the support we've 
already had since he took the chairmanship. It has been a busy 
time, and he carved out time not only to meet and talk at some 
length with myself, but also, as he mentioned, travelled to 
Colombia and began looking at some of these programs and the 
crush on business.
    I'd also like to thank you, Chairman Souder, for the 
tireless work you've already done on this. We have personally 
travelled together through a number of countries in this 
hemisphere, including Bolivia, Colombia, Canada, as well as 
worked extensively on this issue, and I look forward to working 
with you again and thank you for your dedication here.
    I'd also like to thank Ranking Member Cummings for his kind 
words. As he knows, and I've said to him privately, it has been 
one of the pleasures of this job working with him on some of 
the problems in Baltimore. We know we don't make people well 
sitting in our offices and making the policy. We've tried to be 
more proactive, because I know the reality that Baltimore faces 
of no city, I believe, in the history of this country has 
suffered more from the problem of substance abuse and addiction 
than Baltimore, and our goal is to make it the best example of 
a city that comes back. And that is not something we do alone, 
but it is part of what our partnership requires.
    Also Mr. Davis, it was my pleasure to meet with you in 
Chicago, and he spent time with us at the Safer Foundation in 
part of an effort to also try to work with a variety of 
providers and to learn what goes on in the country as we shape 
policy and program.
    So, thank you all. You've all been very active, and I look 
forward to working with other members of the committee as this 
process goes on.
    If it is acceptable to the committee, I'd like to ask that 
my written statement be included in the record, and I'll just 
summarize some of the things and then proceed as we get to 
questions with the topics you think are most appropriate.
    We're here as a next stage to ask your help in allowing us 
to implement the ambitious program outlined or proposed by the 
President in the State of the Union. We believe that the 
centerpiece, as your comments have indicated, to what we need 
to do about the problems of drugs is to treat more people who 
have dependency. It is not the only thing that we do, but it is 
a crucial part of what we're going to do if we're going to make 
this problem smaller.
    I'm pleased to be joined by Administrator Curie, who we've 
worked with tirelessly, and by Dr. Barthwell, whose expertise 
and whose background as former president of the American 
Society of Addiction Medicine. She has been willing to 
generously give of her talents and time. I could not do what I 
do without her help, and I would like to publicly say that and 
thank her, and for the tireless work that she has given to this 
effort.
    The initiative that we have proposed in expanding treatment 
complements the other Federal support to treatment, but it does 
provide a new way to direct those dollars. We've consulted with 
some of the foremost treatment and professional associations 
throughout the country throughout the last year, and we've 
consulted with them since the announcement of this proposal.
    We've been gratified by the endorsements we've received 
from individuals and organizations such as Lawrence Brown, the 
president of the American Society of Addiction Medicine, the 
society that Dr. Barthwell was president of previously; Mark 
Parrino, president of the American Association for the 
Treatment of Opioid Dependence; Linda Hay Crawford, executive 
director of Therapeutic Communities of America; Arthur Dean, 
chairman of the Community Antidrug Coalitions of America; 
Melody Heaps of National Treatment Accountability for Safer 
Communities [TASC]; Phoenix House, the Nation's largest 
nonprofit substance abuse agency; National Black Alcoholism and 
Addictions Council; the National Asian Pacific Americans 
Families Against Substance Abuse; Pride Youth Programs, the 
largest youth prevention organization; the National Association 
of Drug Corps Professionals; and Alcohol and Drug Problem 
Association of America. These are some of the foremost groups 
in the country. We've benefited from their expertise and 
consultation, and we appreciate their support as these efforts 
go on.
    We've made clear, and you all agree, we have to push back 
against the problem of illegal drugs. We ought not to 
surrender. We ought not to be cynical. We ought to do our job 
to make this a smaller problem in America. The President 
forthrightly set the national goal of a 10 percent reduction in 
2 years and a 25 percent reduction in 5 years of the number of 
Americans who use drugs. There are hopeful signs that show that 
we're making progress.
    The Monitoring the Future Survey of 8th-, 10th- and 12th-
graders released in December showed that last year we had drops 
of 11 percent for 8th graders and 8.4 percent and 1.2 percent 
respectively for the 8th, 10th and 12th grade populations. 
We've had other surveys that indicate that drug use may be 
declining in different rates shown by different surveys. The 
Pride Survey of School Children found a 14.3 percent decline in 
past month's drug use by junior high school students. This is 
an important, encouraging momentum, but we have to follow 
through. We're not where we want to be. We want to capitalize; 
we want to accelerate on this.
    What treatment means for our policies can be seen, I think, 
in the National Drug Control Strategy, because it is the center 
of three pillars. The first is stopping drug use before it 
starts through education and community action. The second, as 
Congressman Cummings mentioned, is healing America's drug users 
by getting treatment resources where they are needed and 
helping people successfully get into recovery and stay there. 
Third, we are dedicated to disrupting the market that is the 
drug trade, the poison that is marketed to too many Americans 
and infects, of course, peoples throughout the world.
    These strategic pillars are designed to work together to 
give balance and to give a magnitude of power that neither one 
of them alone would provide. When substance abuse treatment 
leads to recovery, we advance our goals. The demand for drugs 
goes down. The economic basis for the drug trade is damaged. 
Prevention is strengthened because drug users are the carriers 
of the disease of drug addiction. Most importantly, we save 
lives, of those who are users, of those around users, and of 
the communities which use affects.
    The scope of the need for treatment that we affect is 
outlined in the National Drug Control Strategy, and some of you 
in your opening remarks have alluded to his. We have identified 
roughly 6.1 million individuals needing treatment because of 
the nature of their drug use, abuse or dependence; 76 percent, 
however, have yet to recognize that need. That is 4.7 million 
people that are in a form of what we call the denial gap. 
Seventeen percent did receive treatment at some time during the 
year, previous year's survey, in a specialty facility. That's 
1.1 million people. Five percent need treatment and recognize 
the fact, but nevertheless did not seek it, over a quarter of a 
million people, and 2 percent, approximately 100,000 persons, 
sought treatment, but did not receive it for their substance 
abuse or dependence.
    This latter group have demonstrated an immediate need for 
services and a willingness to seek help. They deserve a 
response to their courageous efforts to change. This response 
is a central feature of the President's voucher initiative. 
That is not to say we do not intend to strengthen efforts to 
reach the other people in these categories, but we have people 
who are coming forward for help and are not being helped today. 
We'd like to start with that population in more cases and more 
places.
    The vouchers provide immediate impact and access to 
treatment. As we've tried to define the program, the $200 
million a year for each year, fiscal years 2004, 2005 and 2006, 
complements the nearly $3.6 billion budget for substance abuse 
treatment, a total increase of $271 million over the 
President's fiscal year 2003 request.
    As intended with those without recourse, the private 
insurance or other Federal support such as Medicaid can be used 
for substance abuse, dependency and abuse, including alcohol. 
It builds on current State incentive grants, the Substance 
Abuse Prevention and Treatment Block Grant, and the Targeted 
Capacity Expansion Grants, as some of you mentioned.
    The initiative, we hope, will expand treatment capacity. 
The initiative builds on community outreach to overcome the 
denial gap. It will serve more people more efficiently and will 
increase effective treatment. A broader base of treatment 
providers, proprietary, nonprofit, government-run, 
nongovernment-run providers, we hope, will be encouraged to 
enter the system. Existing treatment providers will be held to 
higher expectations of performance, and expanded capacity will 
be targeted to actual local need.
    The so-called IMD exclusion that has prevented some 
providers to provide residential care in larger institutions 
would not hinder this program. The so-called IMD exclusion 
would be lifted. The initiative would not exclude those 
providers who offer resources tied to faith as part of the 
process of recovery, as some of you have mentioned.
    The current medical and mental health providers have an 
opportunity to offer substance abuse services that would be 
funded if they are effective. The initiative builds on a system 
of professional assessment and referral with the provision of 
vouchers flexible enough to meet individual need. Whenever a 
person receives medical care, they can enter the system. 
Additional community resources can play a role with employers, 
family members, schools and houses of worship. We have many 
people who need assessment who are not facing up to their need, 
and we know when we create gaps, people fall through those 
gaps. We want the assessment, the referral and the resources to 
be tied more closely together.
    The initiative uses the instrument of choice to broaden and 
strengthen the treatment system. It brings target treatment 
resources into line with actual community need, enables a 
better match of specific specialty service need with treatment 
modality. It provides flexible services, offering a continuum 
of care from early intervention to detox to in-patient 
residential services depending on the need.
    The initiative insists on performance outcomes and rewards 
efficient services that deliver on the promise of recovery. 
Standards will be built into the system when States compete for 
the grants, and the standards are required to measure effective 
outcomes built on a competitive State grant system with State 
oversight for eligibility to provide services; insists on 
monitoring and reporting of outcomes for continued 
participation.
    Evidence-based and standardized treatment assessment and 
referral will be a part of this program, and a variety of 
measures can be used to evaluate effectiveness. Criteria must 
include abstinence from substance use as one of its factors.
    We will work with the States to adapt these requirements 
and needs to State situations, and we will allow the program to 
be deployed with maximum, hopefully, ability to use the 
resources and capability of individuals, States and communities 
as well as their needs.
    Because the initiative represents new money, States have an 
incentive to meet our standards and improve their treatment 
systems, we believe, to a greater extent. The initiative brings 
accountability to substance abuse treatments. We not only want 
to reach those who have not before had access to treatment, we 
want to insist on those who receive treatment actually achieve 
recovery in more cases.
    In 2002, nearly 1.2 million individuals received treatment 
services, but too often they did not achieve full recovery. The 
treatment system must be strengthened, with effectiveness being 
the key requirement, and also, when they fail, to get them back 
into treatment, into another form that is more effective to 
them. We will reward what works with this system. We'll have a 
system that expects to make a difference, and the voucher is a 
tool for shaping and improving that system, we believe.
    The key to accountability is a mechanism of payment. Full 
reimbursement follows from demonstrated successes is what we 
are proposing as a guideline as we work out the specifics of 
this program.
    Let me close by saying that healing America's drug users is 
the responsibility of a compassionate Nation. I have not met a 
single Member of Congress or a member of the public that 
doesn't believe that, and too many people are disheartened by 
the number of people who don't get help and are not healed. We 
insist on doing better, and the President has charged us and 
the administration with being more aggressive and more direct 
in meeting that cry for better results as a Nation for those 
who are suffering.
    Providing effective resources for recovery saves lives and 
strengthens our country. When people accept their 
responsibility to change, we can meet them and help free people 
from addiction. This initiative is an important new tool in 
meeting these challenges, and I appreciate the opportunity to 
talk to you today about it and to work with you in helping more 
people integrate back into the opportunity that we all want for 
all Americans. Thank you very much.
    Mr. Souder. Thank you very much.
    [The prepared statement of Mr. Walters follows:]
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    Mr. Souder. I'd like to now welcome my long-time friend, 
fellow Hoosier, Charles Curie. Everything he says that's right 
today is because he was born in Indiana. Everything he says 
that's wrong is because he lived in Pennsylvania too long. 
Welcome, Mr. Curie.
    Mr. Curie. Thank you, Mr. Chairman. I appreciate the 
opportunity to be here. I appreciate, too, the opportunity to, 
again, see my good friend and fellow Hoosier. I think last time 
I had an opportunity to meet with Ranking Member Cummings, as 
well as Mr. Davis was at the field hearing in Fort Wayne, IN. 
And I was back home in Indiana that day, and it was, I thought, 
also a tremendous field hearing focusing on that intersect with 
criminal justice which you emphasize today, which is a very 
important part of all we do.
    Also, Chairman Davis, it has been a privilege and pleasure 
to speak with you beforehand, and appreciate your support, as 
well as members of the subcommittee, Mr. Clay.
    I would like to ask that my written testimony be submitted 
as part of the record, and on behalf of Health and Human 
Services Secretary Tommy Thompson, I'm very pleased to share 
this opportunity with Director John Walters, with whom we have 
forged a very strong relationship with and have appreciated 
very much the partnership, the guidance and the direction and 
the leadership that Director Walters has provided, as well as 
the relationship with Dr. Andrea Barthwell. I've appreciated 
that very much, and it has been, I think, a great collaboration 
within the administration.
    And it is a privilege to discuss President Bush's proposed 
substance abuse treatment initiative today. This new initiative 
continues to fulfill the President's promise to invest $1.6 
billion new dollars in addiction treatment over 5 years. Of 
that $1.6 billion he proposed in the State of the Union, $600 
million over the next 3 years is for this initiative. The first 
$200 million installment is included in the President's 
proposed 2004 budget for the Substance Abuse and Mental Health 
Services Administration [SAMHSA]. SAMHSA's statutory authority 
for administering this program is provided under sections 501 
and 509 of the Public Health Service Act.
    SAMHSA's vision, a life in the community for everyone, is 
clearly consistent with the President's substance abuse 
treatment initiative. SAMHSA's vision is achieved by 
accomplishing our mission, building resilience and facilitating 
recovery. Working together with the States, local communities 
and public and private sector providers, we work to ensure that 
people with or at risk for mental or addictive disorders have 
an opportunity for a fulfilling life, a fulfilling life that is 
rich and rewarding and includes a job, a home and meaningful 
relationships with family and friends.
    To provide treatment services for people who have substance 
abuse problems, SAMHSA currently funds, as has been mentioned, 
the Substance Abuse Prevention and Treatment Block Grant and 
Targeted Capacity Expansion Grants. The block grant with its 
required maintenance of effort will continue to support and 
maintain the basic treatment infrastructure which exists in 
States throughout the country.
    For fiscal year 2003, the block grant totals nearly $1.8 
billion. Targeted Capacity Expansion Grants, which total 
approximately $320 million for fiscal year 2003, are awarded to 
State and local governments to address new and emerging 
substance abuse trends and to respond with treatment capacity 
before problems compound. This ensures us flexibility and gives 
us agility to meet treatment needs in the most relevant way.
    The President's new substance abuse treatment initiative 
provides a third funding mechanism to expand substance abuse 
treatment capacity. It will utilize vouchers for the purchase 
of substance abuse treatment support services. Specifically, it 
clearly enables us to accomplish several objectives that have 
long been identified by those in the field, policymakers, 
legislators, and the very people we serve, as critical to 
moving the substance abuse treatment field forward.
    The first objective is to recognize that there are many 
pathways to recovery. For the first time individuals will be 
empowered with the ability to choose a provider, whether 
nonprofit, proprietary, community-based or faith-based, that 
can best meet their needs. The very personal process of 
recovery can include meeting a person's physical, mental, 
emotional and spiritual needs. In particular for many 
Americans, treatment services that build on spiritual resources 
are critical to recovery. We must work to ensure that all 
Americans are allowed a full range of treatment services, 
including the transforming powers of faith. Denying these 
resources for people who want to choose and need them denies 
them the opportunity for recovery. Vouchers will allow recovery 
to be pursued in an individualized manner, and, in other words, 
we're able to realize the epitome of accountability, which is 
consumer choice.
    The second objective is to reward performance. The voucher 
program will offer financial incentives to providers who 
produce results. Outcomes that demonstrate patient successes, 
including no drug or alcohol use, employment and no involvement 
with the criminal justice system, will be used in determining 
ultimate reimbursement. Never before have we been able to so 
clearly recognize outcomes as part of the quality and 
effectiveness equation.
    Finally, the third objective is to increase capacity. The 
new resources will expand access to treatment and the array of 
services available. Vouchers can be used to pay for medical 
detox; in-patient, out-patient treatment modalities; 
residential services; peer support; relapse prevention; case 
management and other services supporting recovery.
    To implement the President's initiative, we plan to issue a 
request for applications late this summer, early fall. The RFA 
will be based on SAMHSA's State and Senate grant model and will 
be awarded to Governors' offices. We believe the Governor is 
key to ensuring a coordinated approach among various State 
departments such as State drug and alcohol authorities, mental 
health authorities, departments of education, child welfare, 
Medicaid and criminal justice agencies. After all, each of 
these arenas provide services to people with addictive 
disorders.
    We are working with the States, because they are our 
primary resource for substance abuse treatment services. These 
services are funded through State revenue and Federal programs, 
including SAMHSA's block grant, Targeted Capacity Expansion 
Grants and some Medicaid dollars. We want to ensure the new 
voucher program is coordinated and integrated into these State-
operated programs.
    We'll be working with multiple stakeholders, including 
States, providers and national associations, to develop the 
RFA. The RFA will include broad standards and consistent 
performance expectations. Financial data will be used to 
monitor costs and to ensure that funds will be used for 
appropriate and intended purposes. Performance data will be 
used to measure treatment success and ultimately to measure the 
success of the voucher program.
    We expect that successful applicants will establish the 
following: Demonstrate a need based on data; present the most 
feasible approaches consistent with the voucher program's 
guiding principles; eligibility criteria for providers; 
eligibility criteria for clients; criteria for matching clients 
with appropriate treatment; standards costs/reimbursement for 
treatment modalities.
    Critically, States must use these funds to supplement and 
not supplant current funding; therefore truly expanding 
capacity.
    We see the President's initiative as a unique opportunity 
to bring profound change in the financing and delivery of 
substance abuse treatment services. As the President said, our 
Nation is blessed with recovery programs that do amazing work. 
Now we must connect people in need with people who provide the 
services. We look forward to working with you, the Congress, 
our Federal, State and local partners to make this program 
successful for the people we all serve. Thank you.
    [The prepared statement of Mr. Curie follows:]
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    Mr. Souder. Thank you both.
    I'd like to start with a capacity question. Director 
Walters in his statement talks about the utilization rate, in 
that there is a deficit of those actively seeking of around 
100,000. In your statement it says it is particularly 
pronounced in areas for juveniles, services in rural areas, 
needs of women and mothers, and those who suffer co-occurring 
mental disorders.
    And in Mr. Curie's statement, you did two things, and this 
is the first question I have to try and reconcile with this, 
and it gets directly to the heart of where the program is going 
to go, because you said that at the end there that there is a--
that the Governors will have to show an increase in capacity, 
but you also described the--that this will--the vouchers could 
be used for medical detoxification, in-patient or outpatient 
treatment, modalities, residential services, peer support, 
relapse prevention, case management and other services 
supporting recovery, not all of which is the first round of a 
treatment.
    So my first question is, is the 100,000 shortage of people 
who are seeking people at the initial stages who can't get 
that, or would that include relapse prevention and other types 
of things?
    Mr. Walters. Well, I can let my more expert colleagues 
elaborate, but the 100,000 is not a census, so we have an 
estimate based on a survey of the country that is a 
statistically representative sample, but it doesn't have the 
fine grain to kind of tell us precisely where that 100,000 
people are, all their demographic characteristics, because of 
the cost of having such an extensive survey.
    Fortunately, however, the drug dependency, the drug problem 
is too big, but it is not so big that you don't have to do 
fairly intensive surveying to kind of find the demographics of 
small subpopulations. We know from other data, though, that in 
particular areas there are underserved populations of some of 
those that you enumerated, and we have, as I think you alluded 
to, the ironic situation or the tragic situation I guess is the 
better way to put it, of surveys for the last 10 years of 
capacity utilization of looking at, given the slots we have of 
various kinds, how full are they on any given day, show that 
roughly 20 to 25 percent are vacant on any given day. At the 
same time, we have people who are on waiting lists. We are not 
doing as efficient a job as we would like to do, and I think 
most people would like to do, in matching need to services.
    What the voucher does is you pay for the actual service you 
get. So it would be more efficient, we believe, and we're 
spreading it over the range of services, because in individual 
areas, some of these things are going to be more of a priority 
than others. But the remarks you cited from Mr. Curie are 
reflective from what I've seen and I'm sure you've seen going 
around the country. In many cases specialized services for 
women or even single men, a smaller population, who have 
dependent children--services are lacking. In many cases 
juvenile services are lacking. Many times for adults there 
aren't the different kinds of services and modalities that we 
need. But what this would hopefully do is expand the number of 
people who would offer services of different kinds by 
responding to the need, and also get the people who have the 
need directly with the resources to get the services when we 
assess them as having the need. And I'll let anybody else 
elaborate.
    Mr. Curie. Thank you. In addition--and I agree with 
Director Walters' answer completely--the 100,000 figure comes 
from our household survey, data derived from that, and 
basically individuals in the sample across the country who 
responded to questions which would have indicated that they 
have a drug and/or alcohol problem, and the added feature they 
responded, they recognized they had a problem, and they have 
tried to seek treatment, could not find it. It would be 
anticipated that in that 100,000 would be a range of 
individuals, perhaps first-time individuals reckoning with it 
as well as individuals who have dealt with this before in their 
life.
    Mr. Souder. Thanks. My time is about up. I assume we will 
have a second round. But it leads to a fundamental question 
about the program. Is the goal to expand the services 
predominantly, or is it to better target the services, or is it 
to make the services more effective, all of which theoretically 
could be done, but aren't necessarily overlapping goals? And we 
may have to have some prioritization.
    And also perhaps in a followup written response, I would 
appreciate receiving some more particulars on, for example, the 
services of rural areas. What I found when I was on the 
children and family committee is that many don't service rural 
areas very much, but the numbers are fairly small that would be 
impacted. What you have to do when you have limited dollars is 
to figure out when you're targeting subgroups, is that going to 
be out of 100,000, is that 1,000 people, but it takes up x 
amount of the budget versus a waiting list in Baltimore where 
it may be higher?
    Another variable that I would suggest that you have just 
addressed in your response on the vouchers to some degree is 
the mismatch between capacity, because as a casual observer I 
would say if you have health insurance, and if you are more 
wealthy or have a job, you are more likely to get drug 
treatment. The problem is that mismatch in that the capacity 
may not match, particularly your proposal that you referred to 
in the testimony about going to residential centers with 12 
beds, which may be able to be more at the grassroots level 
which are not currently in the program.
    But one additional thing for the record I would like to see 
is that in the list, you didn't include prison population, and 
you didn't address directly whether low-income and minority 
groups are having a more difficult time. I assume that comes 
partly under your targeted programs in SAMHSA. But if we don't 
get back to it today, if you could respond to those in a 
written way.
    Mr. Cummings.
    Mr. Cummings. Mr. Chairman, I just want to followup on 
something that you just raised that I hadn't thought about. Mr. 
Curie and Director Walters, when we talk about need-based on 
data, rates of abuse and dependence, when you have an area like 
Baltimore and Maryland, the State, we have a lot of people--we 
have one of the highest prison populations in the country, and 
a lot of those folks went in there because of drugs, and sadly 
they come out still with a drug problem. Would that be part of 
the determination--in other words, you have one area that's got 
8,500 people coming out a year, and you have another area of--
where maybe only 500 people come out a year coming back into a 
community, and you can show in the past that there has been a 
drug--some kind of correlation--I don't just want to say that 
because somebody comes out of the prison, they have a drug 
problem--but do you see that as something that would be taken 
into consideration, because that's a major issue?
    Mr. Walters. Yes. In fact, Mr. Davis visited the Safer 
Foundation that's helping to reintegrate people who are coming 
out of jails and prisons, some of whom are also getting drug 
treatment services at the site we visited as well as other 
reintegration help. This is the kind of flexibility we would 
like to build into the program to allow States to provide those 
services where the need is and to prioritize them. We're not 
saying that the whole system isn't working. You know this as 
well as I do. We visited the center in Baltimore together. 
There are people doing outstanding work and serving important 
parts of the population. But there are gaps, and there are just 
overall capacity problems. So we would like to work with States 
and localities to both target where the needs they see are and 
also optimize the opportunities they believe there are to 
expand capacity. There may be a need that they don't think they 
have yet got the resources for, so a first stage may be to try 
to do some training or try to get more people capable of 
meeting that need. We're not trying to say one size fits all 
here, but this is still going to be a partnership with the 
States.
    Mr. Cummings. What we have here, Mr. Curie, is that we've 
got two programs under SAMHSA, as I read your testimony, and 
this adds a third tool to try to address this big problem. And 
so do you see any way that now we have these two programs that 
already are existing in competition in any way with regard to 
this third program, and how will that--how do you see the 
transition going in your department?
    Mr. Curie. Excellent questions. Clearly one of the reasons 
we have wanted to select and utilize the States in the process 
of implementation of this program is States--is where drug and 
alcohol programs are primarily implemented. They're responsible 
for the block grant as well as both communities and States 
Targeting Capacity Expansion Grants and leave these States as a 
point of integration. So we want to avoid any sort of not 
maximizing the funds or any sort of competition, but we want to 
make sure all three major types of funding mechanisms are 
aligned and are working together. And currently now, as 
Director Walters indicated, for the criminal or justice 
population there are dollars in various States from the block 
grant that are working toward both in conjunction with drug 
courts as well as reentry programs as well as we have Targeted 
Capacity Expansion Grants that are targeted. We also have a 
partnership with the Department of Justice with the major 
reentry initiatives, and we see those continuing.
    We obviously, as Director Walters indicated, would be 
looking at States as they propose how they would use this 
voucher program of how they would address a criminal justice 
population. That's clearly not precluded. One caution is 
obviously treatment within the prisons has historically been 
the criminal justice department's responsibility. So we would 
want to be careful there's not supplanting.
    Mr. Cummings. I was talking about once they get out, you 
can always project how many are going to come out.
    Just to piggyback on something the chairman mentioned, 
whenever I see anything like this, I try to think as a lawyer, 
and I think about the counterarguments and how do we get 
consensus. And I can imagine that someone who is from a small 
rural area, for example, I have a lot of rural areas, would 
have the concern that the chairman just raised--that, you know, 
how do you make sure that when you have problems in those 
areas, that the money just doesn't all go to the big areas? 
Because, I mean, if we took a Baltimore City situation, and 
that is just 1 out of 24 counties, by the way, in Maryland, 
with 65,000 addicts, you know, if I am Congressman Souder, I 
might say, oh, my God, is all the money just going to go to 
that glaring problem as opposed to the problem that we saw in 
Fort Wayne, which I don't think is as glaring, but for the 
people that are affected, it is pretty bad.
    So how do you all see that? I know you have your two 
programs already, but about this program and making sure we 
don't have a situation where--and I know this is sort of 
arguing against my own self, but I want to make sure the 
program happens, and I know how the Congress works. So how do 
you assure that Fort Wayne gets its due also? And he hit on 
this, and I don't know whether you had a chance to answer that.
    Mr. Walters. Well, we are aware that this is a problem that 
is not uniform, but also does not affect simply one area and 
not another. The rural problem tends to be less intense, as you 
indicated. There's no question the heart of this problem is in 
major urban areas, but that is not to say methamphetamine or 
heroin or cocaine don't exist in rural areas.
    The real problem for treatment in rural areas is that if 
you provide services on the basis of building a facility or 
supporting a facility, sometimes in sparse areas--I was in New 
Mexico a month ago meeting with Governor Richardson, and people 
are coming hundreds of miles to try to get services. Well, if 
you have a juvenile or an adult, to have them pull up stakes 
and have them move, that creates enormous problems, as you can 
imagine, or the cost of transportation.
    What the voucher would do, instead of trying to build them 
and make the people come to the services, it would provide a 
mechanism to local health clinics, local physicians, local 
institutions could add more easily the services closer to the 
people. It won't completely solve everything. And I think we 
are interested in showing how this mechanism can work in rural 
areas as well.
    So we would want to look at and we will have to write the 
regulations in a way that does recognize that is a need we look 
at specifically, so we don't just say it's sheer numbers, so 
that concentrations of populations would dominate all the 
money. I have to go where the concentrations of need are as 
well.
    So I would not want to mislead you. And you know we are 
going to end up driving this money to large urban areas because 
that is what we have to do now. But I do think it is important 
to say that we are not neglecting--I don't know of another tool 
that would more effectively solve the problem of access in 
rural areas than this program.
    Mr. Curie. I would just add that clearly, the standards in 
the RFA we issue would be looking to States to demonstrate how 
they would assure that they're going to be addressing hard-to-
reach areas, and if the vouchers are there, it also provides 
incentives for services that perhaps had not been there before.
    Mr. Souder. The challenge is how to build certain 
flexibilities, much like in heavily rural Appalachia. You 
simply can't have the same size hospitals and clinics in every 
single place in the United States.
    Dr. Barthwell.
    Dr. Barthwell. I just wanted to add that we've heard this 
figure, 65,000 addicts in Baltimore who on any given date, need 
treatment, and there has been a critical rule of thumb that has 
been followed for some time, and it's borne out over years that 
at any given time, on any given day, only about 15 percent of 
people who have chronic severe debilitating forms of addiction 
are seeking assistance for that. That is based on a number of 
things: their own belief in their potential to recover, their 
own belief in their ability to get help, the way in which 
people around them reinforce their desire to change, whether 
people put pressure on them to take action for the behaviors 
that are being observed, and the cultural conversation about 
addiction and nondependent use.
    So if we were to look at that 65,000 people that need help 
but are not seeking help or not able to get help, they would 
distill to 9,750 who today would feel as if they should go 
somewhere and seek help. And there's a lot of consistency with 
figures in the National Household Survey. We're already 
treating about 17 percent. Two percent said they went out at 
some point during the year and sought treatment, but didn't get 
it. So this program is going to extend that figure to about 19 
percent. So we're doing a little bit better than we have done.
    We also expect in our office to increase the pressure to 
change the cultural conversation so that more people recognize 
that they have a problem and develop a desire to change and are 
compelled by the people around them to go out and seek 
treatment. So we think that this President's treatment 
initiative is going to address the 2 percent that went out and 
sought help and didn't get it, but we fully expect if we can 
continue to change the cultural conversation about drugs in 
America, that number of people who feel as if they need help on 
any given day is going to go beyond that 19 percent, and we 
should prepare for having people seek treatment earlier so that 
they are not experiencing chronic severe debilitating forms of 
disease. They're getting off that treadmill much earlier than 
they have been.
    Mr. Souder. Chairman Davis.
    Mr. Davis of Virginia. Thank you very much.
    Accountability is an issue that's been discussed here. It's 
the mainstay of the program. In your testimony you both have 
stressed this will be outcome-based programs; that, in short, 
the Federal dollars will not go to programs that don't show 
demonstrable results. In connection with this, just a few 
questions. How do you ensure that the results will be 
effective? Will you test users? What happens to a provider that 
isn't effective? What's the time period for measuring?
    Mr. Walters. We talked about the general principles because 
we haven't written all the regulations and the specifics yet, 
but these are the general principles we have in mind. Once the 
person comes in, is assessed, is referred to a treatment 
provider, gets the services, after the services are completed 
as decided by the provider, that there's a postservice 
assessment. We can talk about how long afterwards or what the 
full ramifications are.
    We care that a component of that assessment is whether or 
not the person receiving the services is abstinent. As Mr. 
Curie said in his testimony, we can look at involvement with 
the criminal justice system; other kinds of issues of 
stability, like employment and others, and we probably should, 
because for some varying degrees of severity of the clients 
that you take in, you can expect varying degrees of 
complications and relapse.
    But we do not want to send the message that the system is a 
revolving-door system. We do want to send the message that the 
system is one built on a premise that while we say we believe 
in it, we don't believe we can make people well categorically. 
Sometimes when you talk to people, they won't say this in the 
open. They will say, well, what we really need to do is be a 
little more hard-headed. There is a category of user out there 
that we can't help, and we ought to be more efficient in 
resources by trying to identify that hard-core category and 
move resources to those outside the hard-core category.
    We, in the strongest possible terms, deny that premise. We 
have been to programs that have taken people in the most severe 
possible state and brought them to recovery. We are not 
identifying throw-away people. And the way to most effectively 
treat them earlier on as well as later is to have programs that 
have to demonstrate accountability. Too much of the system now, 
despite excellent people in the field, too much of the system 
pays no matter what the results are; move bodies through. This 
would give providers an incentive to move people from services 
into transitional help, worry about how they reintegrate with 
their families, with their jobs, with their housing and 
stability. It would not just give no incentive to finish the 
services, kick them out the door and submit the bill. I am not 
saying good providers do that. They don't. But there's not 
enough incentive, we think, in the system to identify those who 
are better.
    So we want an assessment at some period of time, and 
perhaps 90 days after services are provided, that includes a 
test to find out whether or not they are abstinent and rewards 
on the basis who are effectively getting people into recovery. 
If the client is not in recovery, we intend to try and 
structure the system so they can go back and get services from 
another provider that may help them get in recovery, because we 
know that if there is relapse, the quicker we get people back 
into services and treatment, the better off they are. We don't 
want to let go of them and have them fall through the cracks on 
the back end if there is a relapse either.
    Now, that is more difficult than the current system 
frequently provides, but if we are serious about the science 
and the medicine and the result that we know programs can make 
here, we ought to make that an expectation in the structure to 
a greater degree. And we ought to reward people who have 
results, and we want the reimbursement system to drive people 
who provide ineffective care out of business. If you don't 
produce results, you can't make up in volume what you failed to 
do on individual cases.
    Mr. Davis of Virginia. Let me ask Administrator Curie a 
question. If you could capsulize why this is better than the 
previous Federal treatment centers and why the $200 million per 
year couldn't be better spent or just as well spent as part of 
the block grant to the States.
    Mr. Curie. Thank you, Chairman Davis.
    Clearly what this initiative offers that we have not been 
able to achieve or attain up to this point in time is: One, as 
Director Walters outlined, a more efficient, quicker pathway to 
accountability being a clear measure around these new dollars. 
And you can do that with a new initiative as we shape it with 
the standards in the RFA.
    Second, consumer choice, which we referred to as the 
epitome of accountability, clearly is essential here. It is not 
an issue of certain providers having received block grant 
dollars year after year and being primarily--while they have 
been a mainstay--and again, we anticipate many of those 
providers are going to be eligible providers to receive and 
benefit from this voucher program as they are able to expand 
capacity. But again, consumers will be in the driver seat, so 
to speak, in terms of where they choose to obtain their 
treatment.
    I think the other aspect is that with these new dollars and 
with the focus on taking a look at expansion of capacity, we 
also can be very clear about the array of services that 
encompass recovery and using recovery as a framework. And 
again, as the voucher program succeeds, and as we move ahead 
with implementation, we're going to be in a position to gauge 
those results from the outset if we have the agreed-upon 
outcomes.
    Mr. Davis of Virginia. Thank you, Mr. Chairman.
    Mr. Souder. Before yielding to Mr. Davis of Illinois, I 
would like to welcome Mr. Bell of Texas to our opening hearing 
this year.
    Mr. Davis.
    Mr. Davis of Illinois. Thank you very much, Mr. Chairman.
    Following up on the voucher program, how do we ensure that 
individuals won't just kind of shop around from place to place 
looking for a miracle cure? Let's say I am at the Davis Center 
for a month, and nothing seemed to have happened that has 
changed my desire. And I say, well, I am not sure these Davis 
people can do it, so I am going to run over to the Cummings 
Center. How do we prevent that from happening with the voucher 
program?
    Mr. Walters. One of my colleagues is more expert, but my 
experience in visiting centers is that's the course that can 
happen right now. You can walk from one place to the other. You 
can drop out. We have problems with retention as a part of the 
programs.
    One of the things this program would do is, of course, in 
order to receive the reimbursement for the voucher, you have to 
show that you are able to provide full services; you got to be 
able to retain people as well as the results of that retention 
and successful recovery. So in a certain manner here, we are 
making the provider accountable by saying you have to keep 
people in. We know for treating this disease, unlike, as an 
example, an attack of appendicitis where you go to the doctor, 
you have a pain, you want to get better, you comply. You know 
that we have been involved in this in a long time, but there is 
a lot of denial. People frequently come in and say, I don't 
really want to stop using; I just want to get it back to where 
I had more control of the fun I am having with drugs. And that 
is a problem we all deal with in providing these services. But 
we think the best way to do that is, one, make the provider 
responsible for retaining contact with the individual so they 
get effective services, and then measuring the effect of those 
services afterwards, and if they are not effective at doing 
that, then moving people to another provider who will be 
effective. So we are trying to address the shopping properly by 
the provider more than we are trying to change the behavior of 
the individual client.
    Mr. Curie. Along with the outcome monitoring that Director 
Walters just described, also this system will be driven in 
large part, too, by initial assessment, in terms of assessing 
the need of an individual and a voucher being issued based upon 
that assessment in terms of what the best course of treatment 
and services would be for that individual. So it is not a 
voucher that is going to have a face value to it to be able to 
go from place to place at just clearly what the consumer 
entirely would want to do, but it is going to be structured 
around the assessment of that consumer's need as well. And we'd 
be expecting accountability to be built into the system that 
once a voucher is issued, that there would be oversight in 
terms of a case management aspect of this as well.
    Mr. Davis of Illinois. Dr. Barthwell, you mentioned 
changing the culture of conversation as a way of convincing 
more of this large pool of individuals who are in denial that 
they are in need of services. Could you elaborate a little bit 
more on that in terms of what some of the techniques and 
approaches might be?
    Dr. Barthwell. The demand reduction and implementation plan 
of the strategy involved communicating very broadly with 
Americans that the drug use problem is not just prevention or 
treatment, particularly focused on chronic severe debilitating 
forms of the disease and trying to drive more money in the 
system to build a better ambulance at the bottom of the cliff. 
It really also has to be about creating systems where we can 
check the behavior of individuals who have moved past the 
barricades that say don't start drug use and to get 
nondependent users to recognize that they are on a course that 
is going to change the trajectory of their life long before 
that happens.
    So we are trying to put speed bumps along the way, if you 
will, to get the attention of the nondependent user, and we 
also want individuals around the nondependent user who 
typically looks the other way saying, well, they're doing 
something, and it's not something I might do, but it really 
isn't affecting me, to start to take some responsibility to 
compel the user to get off of that pathway.
    So our strategy is built around prevention programs, 
strengthening our prevention programs and recognizing that all 
of our efforts converge upon those two big goals, to reduce 
drug use by 10 percent in 2 years and 25 percent in 5 years, to 
get the nonuser to increase their resolve not to use, and to 
deter the use. And we do that by having the messages that they 
receive at home mirror those in community institutions and 
having our laws and standards mirror those to really 
communicate very clearly in a concrete way to young children 
that drug use is wrong and drug use is not a good thing to be 
involved in.
    With individuals who have started using, whether they are 
nondependent users or problematic troubled users, we want to 
increase their desire to change by increasing their awareness 
of their need to change. And we are looking at putting in place 
more programs that detect use to deter, because we know the 
detection programs do, in fact, deter use. We are also looking 
at when those detection programs fail to deter, that the 
earlier identification be linked with an intervention. So we 
are working very closely with SAMHSA to have them drive 
programs into hospital emergency departments where physicians 
get better training in identifying someone who comes in after a 
vehicular crash and intervening them and linking them with a 
brief and early intervention.
    There is a tremendous amount of science. We want to apply 
this in a very broad way to drug use. And finally, for people 
who have more chronic severe debilitating forms of the disease, 
we want to increase their desire to change and help them to 
stop using. And we think that the programs that we can do, this 
being among them, to improve the ability of treatment programs 
to reach an individual where they are so they can acknowledge 
addiction, commit to recovery, and work them to reduce or 
eliminate inducements to use are going to enable us to have 
better success rates from our programs.
    Naturally if you have a program that accepts all comers 
with no screening, they get one out of four individuals to stop 
at the end of the treatment program. We can do better than 
that. We have programs that get 97 out of 100 who enter to 
stop. We want to supply the science and technology that's being 
employed in a two-tiered system to more a public system, and we 
think this voucher system helps us achieve that.
    Mr. Davis of Illinois. Thank you, Mr. Chairman.
    Mr. Souder. One question I wanted to insert, I think, that 
potentially would address a couple of the questions here, one 
relating to the potential switching, from the Davis clinic to 
the Cummings clinic, that the second part which would have to 
do with the smaller residential centers with 12 beds, how do 
they meet the standards you're developing? And even the third 
one you just alluded to, which is prescreening and potentially 
screening out, we had some informal discussions, and I wonder 
whether this was going to be part of any of the standards of 
controlling some of the payment to the groups. In other words, 
if you don't complete the program, and you don't stay clean, 
the firm itself doesn't get the money. If that is the 
accountability, if there is a real action for not making sure 
your people are cured, in effect, or at least through your 
program are clean, then the financial burden and the standards 
are going to be placed on the person who's doing the program, 
or they're not going to get paid. And I am wondering if you are 
actually involving that or whether you see that coming in the 
standards.
    Mr. Walters. That is our intent, and we will work with the 
States to make sure that the way we build that in doesn't 
create impossible work demands. I would expect--although it is 
going to vary from State to State. There is some delayed 
reimbursement. In some States there is now an audit after 
reimbursement to see whether or not services were provided 
effectively, and they may pull some money back or sometimes may 
involve some additional money. So there is already in the 
system some structures that are not unlike what we are 
proposing.
    What we are proposing is an assessment afterwards and 
standards that fit the basis of the severity of the individual 
case that individual providers face. We are not trying to drive 
them simply to cream, as Dr. Barthwell indicated, although, as 
she said, we want to help the people we can help more 
effectively. On the one hand, we are not trying to make people 
not treat a category of people. On the other hand, the creaming 
is understood as something we really could help now. We want to 
help them. And so--but the goal here is to use the addiction 
severity indices that have been developed to compare like 
candidates and to have real measures of effectiveness.
    Not to get too far ahead of us, but my personal view and 
not the administration, we have knowledge from the research we 
have been funding, and the programs we have looked at involves 
sometimes much more expensive, involved treatment. It's very 
hard to fund that when the issue is how many slots you are 
funding. You find cheaper treatment, and, therefore, the people 
who may be helped by the more expensive treatment are not given 
those services, and as a result their outcomes are frequently 
not very good.
    I believe that if we begin a process that assesses people 
and shows severity up front, provide the different set of 
providers, and we look at the outcome of those providers, and 
we begin to say, let's not spend money on something that's 
going to be cheap and ineffective, let's spend greater money, 
but instead of just people saying, this must be better, you'll 
have a system that shows the results to concretely justify the 
more intense expenditure of resources because of the outcome. 
We begin to have a system that can continuously show us what's 
happening here, and so we can better manage and make judgments 
about investment of resources for effective outcomes.
    Mr. Souder. Mr. Clay.
    Mr. Clay. Thank you, Mr. Chairman.
    My concern has to do with the cost of the program. The 
President proposed spending $600 million over 3 years to 
significantly enhance the availability and accountability of 
drug treatment in the United States. Does that mean diverting 
funds from existing programs? And what will be the basis for 
the voucher distribution among the States? Will it be based on 
population, needs or what? Has that been devised yet?
    Mr. Curie. These are all new dollars. They're not being 
taken from any other pot of money. And these are all new 
dollars to the Substance Abuse and Mental Health Services 
Administration for that period of time. We are in the process 
of developing standards by which, as we issue an RFA, we'll be 
having States apply. Obviously, we want to have it based on 
both documented need. Also we recognize there's difference 
between States such as California and Rhode Island. So we're in 
the process now of honing in in terms of what would make sense 
for some sort of allocation, but, again, we want to base it 
upon need.
    Also the key here--we use statements that this is a 
competitive process. I want to stress that when we say 
competition, we're talking at a couple different levels. One, 
States have to compete against the standards of the RFA. They 
have to demonstrate that what they're developing is going to be 
meeting the standards of the RFA. And, again, we want this 
implemented in as many States as possible across the country. 
At this point we're not precluding the possibility of trying to 
do something in every State. Some States may choose not to 
apply. But we also recognize that in dealing with $200 million, 
once we have a response to the RFA, we will have a clearer idea 
as to the breadth of the program across the country.
    Mr. Clay. On a somewhat related matter, being from 
Missouri, initially methamphetamine was manufactured and for 
the most part used in the rural parts of the State. Now law 
enforcement is turning up these laboratories in urban areas. 
Have you all noticed a trend where the use is migrating from 
rural parts of a State to urban parts of a State? And any of 
you can try to tackle that one.
    Mr. Walters. It's very general. The general trend of 
methamphetamine has been that it started in the Southwest and 
moved across the country. For example, we have had it for 
several years in Los Angeles. We had it move to some other 
cities in the West. Sometimes it has started in rural areas, 
but there are also, usually depending on whether it's being 
produced in small labs, which are frequently associated with 
the rural use, but there are also large superlabs, as you 
probably know--some are in the United States, sometimes there 
are superlabs in Mexico--and then bringing large quantities in, 
which can be more directly marketed into urban areas. It can't 
be marketed in rural areas, but they can be moved in because 
some of the organizations are also selling other kinds of 
drugs, heroin, cocaine, marijuana. So they have already 
established patterns of use.
    But we have this moved essentially from the West to the 
East, and in some cases it is first seen in a State in rural 
areas, but sometimes it has also been showing up in an urban 
area just depending on how it's produced and what the 
introduction route is.
    Mr. Souder. Mr. Bell.
    Mr. Bell. Thank you, Mr. Chairman, and thank you all for 
your testimony here today.
    As the Chair kindly pointed out in his welcoming remarks, I 
hail from the State of Texas where drug treatment is a critical 
need, just as I'm sure it is in many other States. 
Interestingly, just this past year, in December, the Texas 
Commission on Alcohol and Drug Abuse did a study where they 
found that the total impact of substance abuse in Texas cost 
the State's economy more than $26 billion, and they broke that 
down--came down to about $1,244 for every man, woman and child 
in the State. So you can see it is having a devastating impact 
on the State of Texas.
    But my concern is this: With States suffering through 
historic budget crises--in my State of Texas, the legislature 
is looking on a $10 billion shortfall in this legislative 
session--my concern is the cost of administering a program such 
as this. Not only are States adjusting to the new data 
requirements under the performance partnership grant, but those 
who choose to participate in this voucher program, based on my 
reading, will have to bear the brunt of the administrative 
costs.
    When considering pending State budget cuts, administering 
these programs could adversely affect the very people we intend 
to serve. Currently only small portions of existing grant 
dollars can be used toward administrative costs, and under this 
voucher program, my question is will there be caps placed on 
the dollars going toward administrative costs? And if so, are 
you concerned about the burden this may place on the States and 
what can be done about that?
    Mr. Walters. We certainly are concerned about the problem 
of how much of the resources we want for services get pulled 
off in nonservice delivery here. And I met, in fact, with Dave 
Wanser from Texas, single State agency, just a month ago and 
talked about the pioneering program Texas has and linking 
electronically individual providers to a reimbursement system 
that will save enormous amounts of money. I think SAMHSA is 
already interested in doing this so that the paperwork is not a 
matter of multiple copies of different forms, but a Web-based 
system where information about clients, the assessment and case 
management information, is wed to reimbursement information, 
and that pulls from that the information we need, from reports. 
We're not sending multiple forms and requirements. We're 
reducing the staff costs. We want to cap the administrative 
costs of this program.
    We also want to reduce administrative costs, although we 
are seeing some variation here. Different States have different 
capacities.
    We also want to reduce the cost of providing services that 
are not utilized. One of the things I mentioned earlier that is 
attractive, especially in this budget climate, is that we would 
pay for the services provided. We are not paying for a facility 
or a place where there's a bunch of slots, and the maximum we 
could hope for was use 100 percent, but usually we're going to 
use less than that. When we pay for vouchers, we're paying for 
an actual delivery of service to an actual individual.
    Yes, there probably would be some additional expense 
associated with the followup assessment. Right now I suppose 
there may be some additional assessment or cost in providing 
the reimbursement perhaps, or to bring new providers in line. 
But I don't think, given what we know about the system now, 
that is likely to be significant, and I think it's just not pie 
in the sky promises that the savings on efficiency, the savings 
on funding programs that work, the savings on giving programs 
incentives to change as a result of the reimbursement mechanism 
should vastly outweigh the costs that are involved here, but we 
would not allow uncapped administrative expenses as a part of 
this program.
    But I would let Mr. Curie talk about the structure that we 
have decided on so far.
    Mr. Curie. We're anticipating that in the standards, that 
we would be giving guidance in regards to use of any of the 
dollars to cover administrative costs to the State, and, again, 
we would anticipate that being capped. At the same time these--
one major advantage is that we're not requiring any State match 
or efforts made of these dollars. So that also gives the States 
some greater latitude with these dollars.
    Dr. Barthwell. I would also like to add that we do expect 
that there is a clinical assessment that is done before a 
person is matched, and that the post-treatment assessment would 
be clinically allowable costs and not a part of the 
administrative overhead. We also spoke with Don Weitzman, who 
is the associate director of Dakarti yesterday, and you have a 
5 percent administrative overhead allowable in Texas, and last 
year you didn't use all of it. So they are actually operating 
at--a little slimmer in the way of administrative costs than 
some States are.
    Mr. Bell. Thank you.
    Mr. Souder. I would like to yield to Mr. Cummings.
    Mr. Cummings. Thank you very much, Mr. Chairman.
    As I listen to the questions of my colleagues, I just 
wanted to ask you about a few other things. Director Walters, 
if I've got a Cadillac program, and then I've got a Pinto 
program, and I've got a voucher, Cadillac program costs me 
$100, the Pinto $20, how do I control--I know the States have 
regulations, but how do you foresee having some kind of balance 
here? I know at the end you will look at the results and see, 
and you will maybe look at some costs from the beginning, but 
the other person goes in there and every week he's going in 
there, $100, $100, $100, and then--but he could have gone to 
the $20 program that may have been just as an effective. 
Because, as we all know, sadly, and all we have to do is look 
at Medicaid fraud, a lot of times when people find a way to 
reap dollars, they do it. We have a few bad apples; 99 percent 
of the people are great, but the few--and with the limited 
amount of money that we're dealing with, I am just trying to 
make sure that we have the safeguards that we need.
    And so all of you have talked about how we, the Federal 
Government, what we say to the States. And so how do you deal 
with that kind of situation, because I can see that happening 
because I have seen it just trying to help people get 
treatment. One program is sky high, and another one is real 
low. What do you foresee there?
    Mr. Walters. I will let my colleagues who have more 
experience respond in more detail. I think this program for the 
first time lets us address that problem. We will assess people 
at the point where we give them a referral and give them the 
voucher. If they need more expensive residential treatment 
rather than outpatient treatment, that would be a determination 
made at the point of assessment. Then the referral would be for 
that category of treatment with providers, I presume, in the 
States--although we haven't settled all this yet--that would 
agree to provide those services within a certain range of 
costs. If we find then that some of those providers can provide 
effective services at a much lower cost, then we obviously 
would have the information that's necessary to say, why don't 
we learn from what they're doing and provide more people 
effective treatment at the lower costs.
    There may be some variation. There always is in 
circumstances and situations. One size doesn't fit all. You 
can't always compare people that are in more expensive 
environments. And I suppose there is some variation. For the 
first time--it is not that the voucher is good for anything you 
want, it would be determined on the basis of the assessment, 
what range of intensity and expanse of services. And then 
within those particular providers, we would have over time an 
indication of what was the more cost-effective route, whether 
it is more costly or less costly.
    Obviously, we would like to be as efficient as anybody, but 
we would begin to have the data that shows who is making the 
difference.
    Mr. Cummings. You went right where I wanted you to go, the 
data. Do you foresee a day, once we get the data, that we might 
say, the Cadillac program, we love you, you're nice and all 
that, but we just can't--do we--do you see a date when we say 
that either you are going to bring your costs down, or we are 
going to have to say this is one program you cannot use with 
the voucher? Do you foresee that kind of thing?
    Mr. Walters. Sure. I would imagine with responsible 
stewardship that we would build into this partnership with 
States saying, if you don't do with a lot more money what you 
can do with less money, because there's always going to be 
limits here--but if the system works, we would begin to have a 
record of each provider so we not only can refer you to 
somebody, we can tell you what their effectiveness is. There 
really is consumer choice based on knowledge, and that's when 
it has meaning, and that's when you begin to say we are 
providing a system that maximizes the skills we have as a 
Nation to make people well and to help them get into recovery 
and stay there. It's not a shot in the dark.
    Mr. Cummings. Just on that note, when you said that, it 
reminded me of health insurance open enrollment thing where you 
sort of pick and choose. Do you foresee a time when maybe you 
may say--have some kind of document that says just based on 
pure data that this is what we have seen, these are the 
results? I don't know how deep you want to get into that. Do 
you follow me?
    But again, following the yellow brick road, trying to get 
to the most effective and efficient use of dollars, it seems to 
me like you would almost have to, at some point in this 
evolution of making the program the best that it can be, get to 
there where you are actually listening to stuff and what's 
reasonable and what's not.
    Mr. Curie. I think you have actually addressed the ultimate 
place we want to be, and that is if you want to call it 
scorecards or report cards at all levels. In other words, we 
are going to require States to have a credentialing process, 
which I would view as a dynamic process, as we establish 
standards, and in that credentialing process also permissible 
rate ranges based on modality being part of that as well; and 
then as time goes on, as you indicated, in terms of a list of 
outcomes, that there can be a day which we would hope for that 
when consumers are making choices, and they have a choice of 
certain providers within a particular modality based on the 
assessment, they can make an informed choice based upon a 
scorecard of outcomes, consumer satisfaction and make an 
informed choice. And I think that that is part of the evolution 
that we see in this process.
    Mr. Cummings. Just one other thing I want to say on the 
record, Director Walters, and I forgot to say this from the 
very beginning. I want to say it publicly. Deputy Director 
Salzburg has been absolutely incredible. She has been to my 
district twice in the last 3 or 4 months trying to help us 
address some very pressing needs, and I just wanted to make 
sure I said that on the record.
    Mr. Souder. I want to make sure, in the responses to Mr. 
Cummings' questions, that one of the big innovations in this 
program is this idea of going down to the small residential 
centers of 12 people to look at Hispanic, African American and 
other minority centers that have traditionally been excluded. 
We don't want to make something so bureaucratic and so 
scorecard-oriented that small providers can't get into this, 
because part of what's been happening is rather than 
necessarily a Pinto, let's say VW Bugs of the world actually 
may be producing as good a result or better than some of the 
big ones, particularly in the hard-to-reach population, but 
they haven't been involved in these kind of programs.
    As a firm believer in capitalist principles, which I 
believe you're building into this program, in effect if someone 
doesn't provide an effective program, they're going to go broke 
because they won't get paid. If you withhold some of the 
payment, they won't be there for very long. Most of these 
places are struggling already, and what we don't want to do is 
make it so that only the people that know how to work the 
insurance system or the people who know how to fill out the 
forms or the people that know how to market with their 
advertising programs are eligible to do drug treatment, because 
so much of this is happening by the love and the individual 
commitment, and that's partly the innovation of your program. 
So don't overbureaucratize the program in developing it.
    Mr. Davis had an additional question, too.
    Mr. Davis of Illinois. Generally and oftentimes when we 
talk about reentry, people begin at the point of an 
individual's termination of sentence, and they're now ready to 
come back into the community. And while I recognize that while 
incarceration is in effect, these individuals under the 
jurisdiction of the various justice and correction facilities 
and institutions of which they are a part--but I really think 
you folks know more about treatment than they do--are there any 
serious efforts under way to convince justice and corrections 
people that they should look seriously to increased treatment 
while individuals are under their jurisdiction, are 
incarcerated?
    Mr. Walters. Yes. In my written statement, in our own 
budget we are proposing an expansion of Federal support for 
drug courts. We have tried to allow more Federal resources of 
treatment to go into the criminal justice system in various 
levels. We would like to do more of this. We would like to have 
this program also have the flexibility based on States' 
determination of need of helping people who come into the 
criminal justice system if they need a voucher for treatment.
    I know there is a view that in some places people come in 
once, and they get harsh sentences. The problem we face in most 
jurisdictions that I have visited is the people come in over 
and over again, and it's not until something serious enough 
happens that they finally get into the criminal justice system 
or they get into something like drug court. It's the reverse.
    We're not reaching out to people when we first should 
assess them because of lack of capacity or resources or lack of 
confidence that it really is going to be cost-effective. We did 
not just say that we believe treatment would save lives and 
save money. We're trying to build a system that acts on that 
principle in a more aggressive way, so when someone comes in or 
when someone is in another community setting where they show 
signs of needing services, there's more people to assess them, 
and there's a more direct link between if you discover it, you 
can actually help them.
    Of the roughly 6 million people we talked about needing 
treatment, 23 percent are kids. They're in schools. They're in 
pediatricians' offices and general practitioners' offices. 
They're coming into community centers. They're coming into the 
criminal justice system as their problems get worse. Before 
they become a serious felon, or before they drop out of school, 
or before they fall away from home or don't see pediatricians 
anymore, we want to encourage people that reach out to them by 
giving them a clear statement of obligation--that's the 
cultural change that Dr. Barthwell spoke about--but also we 
want to provide a direct tool to use to get these people help 
even if it's less intensive help earlier on, because we know 
that creates the greater chance of recovery.
    Mr. Davis of Illinois. I am saying specifically, though, 
while they're in the penitentiary, while they're in jail, are 
we talking to wardens and prison officials saying that you 
folks might want to look at increasing the amount of treatment 
that you provide to these individuals while they're inmates?
    Mr. Walters. Sure. We also agree that we think to optimize 
this we need to pair the incarcerated treatment that we're 
providing to reintegration programs out in the community. I 
think there's no question we increase the effectiveness of 
those programs when we do that, and dramatically. So we want to 
do that as well.
    But I don't want to be understood to be in any way evasive. 
We want more treatment in the places where people have problems 
are, and one of those places is prison.
    Mr. Souder. Before yielding for Mr. Mica, I have some 
additional written questions I will submit.
    I also want to reiterate a couple of points that you have 
made here, and I think they've significant, and we look very 
much forward to seeing how it comes down to the details. And 
when you put your RFPs out, the idea of having the different 
dollar size based on the assessment because some people are 
going to take more treatment is a very valuable tool. I think 
your tough accountability standards is a new innovation that we 
need to have, and actually having accountability with that, not 
just that they did the test, but that would be tied to whether 
or not the company gets its full funding. I think this should 
also lead to those programs that are effective being even 
stronger programs and more known for their effectiveness.
    But your flexibility in the vouchers and reaching out to 
new groups with flexibility of addressing it is another 
important innovation, and you have expanded in a little more 
detail today that has been very helpful, and we will be very 
much looking at the specifics.
    Clear, we didn't get into the faith-based fireworks today. 
We know we're going to be dealing with that. We look forward to 
working with you. We know part of the difficulty this is--many 
of these very effective programs are predominantly religious, 
and clearly dollars can't be used from the Federal Government 
for the religious portion of it, and this is going to be our 
most hotly debated part on the Hill. And as we move through our 
hearings on faith-based in general and on this program, we'll 
look at those nuances. I have differences with some of my 
colleagues in how far we can go on that, but there are 
Constitutional limitations, and this is going to be probably 
the toughest part of your RFPs when you put it out, and I look 
forward to working with you as you develop that.
    Mr. Mica.
    Mr. Mica. Thank you, Mr. Chairman. And one of my concerns 
is that we've made some of the treatment programs sort of 
swinging doors, and we have people coming in and out of these 
programs for a short period of time and not very successful 
results. It appears from what we've seen there are a couple of 
successful programs. The faith-based have a very high rate of 
success that I've seen, and then longer-term treatment programs 
that are sort of holistic in their approach, they address a 
whole range of problems, but not the short 30-day, sometimes 
60-day.
    Is there any way we can be assured that this new program, 
voucher program, is directed toward these more successful 
programs? Is there any way to start taking money out of these--
they are sort of treatment mills that have sprung up that 
aren't that successful. I mean, we need to put the money where 
they can do the most good. Can you respond?
    Mr. Walters. Yes. One of the fundamental principles that we 
try to build into this is that the reimbursement system based 
on an assessment of the effectiveness of the services provided 
would be a vehicle for determining effectiveness and changing 
the dynamic of the marketplace so that programs are not 
affected--that are not effective do not continue to be funded. 
So the direct way to stop the revolving door, whether that is a 
result of taking in people, letting them drop out at high rates 
or taking in people, giving them adequate care, is that there 
will now be on a case-by-case basis under this program an 
evaluation of what happened to the person, and the payment to 
the provider will be based on being successful. It will vary 
depending on the severity of the individual.
    Mr. Mica. Will there be some way to stop--I mean, you're 
going to be getting data that will be received sometime much 
later in the treatment process, much later. Will you have an 
automatic cutoff if this isn't successful, and what data are 
you going to encourage the States to use in establishing 
whether their programs receive funds under this new program?
    Mr. Walters. We'll work with them on some of the specifics, 
but the general principles that we've talked about in closing 
in the program is that some point after services are completed, 
like, for example, as I said earlier, 90 days, there's a 
subsequent assessment of the individual. That assessment, we 
are saying, must include whether or not they are abstinent. It 
can include other factors, have they been involved with the 
criminal justice system, are they employed and stable, but it 
must include are they continuing to use substances----
    Mr. Mica. Maybe I should back up, because this is 90 days 
into it. Most programs I have seen that are successful are 
longer term. When we get in trouble is when we have these 30-, 
60-, 90-day wonder programs, and they're out for a little 
while, and they're back in for another 30- or 60-day shot at a 
program. And sometimes this is--I mean, I can give you many 
cases of just people I personally know that have had family 
members with an addiction problem, and we have the mills that 
are treating them, and we don't have the results.
    That's why I go back to the original part. Is there any way 
to make certain that this is directed toward programs that 
already have records of success like faith-based, where we 
have--you know, some of mine have a 90 percent success rate. Or 
DETAP, for example. You're familiar with DETAP?
    Mr. Walters. Uh-huh.
    Mr. Mica. I mean, we visited there. I think Chairman Souder 
and I were up there, maybe Mr. Cummings joined us, but they 
took some people that had been addicted for years and had 
criminal records and in and out of the system and treatment 
programs all over the place, and they turned some of those 
folks around. I thought it was a miracle program, quite 
frankly, and that is the kind of program I'd rather spend the 
money on. And I'm not sure that this new program is so 
directed, especially when you tell me that after 90 days----
    Mr. Walters. I don't think I was clear. I meant 90 days 
after the program says it's completed the services to the 
individual. If those services take 180 days----
    Mr. Mica. Can you back up and go to, again, how do we 
ensure that the money gets to these successful programs? Do you 
have some criteria right off the bat to----
    Mr. Walters. We would work with the States to determine who 
is eligible to be a provider under this program. They would 
indicate who they would allow as a referral, and since it is a 
competitive process, we can look at the strength of the 
criteria they use to select and for effectiveness as a part of 
the choice of whether or not they are a participant. In 
addition----
    Mr. Mica. Do you have any kind of rating system in place or 
certification of these programs?
    Mr. Walters. Well, there is a certification system now in 
place.
    Mr. Mica. No. I mean, based on success.
    Mr. Walters. It varies. I'll let Mr. Curie talk about----
    Mr. Mica. Because maybe that is something we should look 
at. Again, I see dozens and dozens of treatment centers across 
the landscape and, again, the revolving door that concerns me, 
and I have no problem. I'll put all the money that we could 
possibly put into programs that are successful, but it's just 
the frustration of, again, putting people in these short-term 
mill programs that have sprung up and that aren't successful.
    Ms. Barthwell. Might I add a little bit to that. There is 
very clear criteria that's been established by the American 
Society of Medicine. There are others. It's been employed in 
the State of Illinois. It's been employed in Massachusetts. So 
there's experience in both the research domain and the clinical 
domain that shows that there's a good relationship between the 
severity of the disease and the intensity and the length of 
treatment in terms of predicting an outcome.
    The American Society of Addiction Medicine's domains that 
they measure are acute intoxication or withdrawal; the 
biomedical problems; the emotional behavior, complications 
associated with it; but more importantly as it relates to why 
someone would need one of the long-term therapeutic community; 
relates to assessing their treatment acceptance or resistance, 
whether they have an insight into the nature of their disease 
and whether there's a potential that they're going to be 
compliant, whether they're highly symptomatic and have skills 
to keep them sober, and whether they need structure and 
support.
    But not everyone who uses drugs who comes in for treatment 
needs a DETAP village in order to be successful, and what we 
want to drive into this program is an assessment as they enter 
treatment to determine who would need that so that they don't 
get the 30-day program.
    Mr. Mica. I just don't like two tries and you're out of 
these quick-shot treatments.
    Ms. Barthwell. We certainly hope they don't get matched to 
them if they need something more.
    Mr. Mica. You just hear so many people that have had their 
kids in or their family members in time after time, again, and 
they are programs that I don't think are successful. And most 
of the programs are geared to this shorter-term treatment. So 
I'm trying to figure out how you--how we give some preference 
to the longer-term treatment.
    I mean, OK, you've got an individual who is addicted, and 
they have one shot at maybe one of your one-stop, quick-wonder 
treatment programs, but then two and three bites at the apple. 
When do we sober up and say we need--this person needs some--if 
we're going to put Federal money into this, we need a program 
that is going to be successful and has some basis for success.
    Mr. Walters. I hope--I'm not sure that we're doing what we 
should do here. We need to convey to you that concern is at the 
center of what we're doing, that the current structure--I think 
sometimes even in the private market, but certainly in the 
government market, has drifted not in all cases and not all 
places we want to have a slot for everybody, and we're not so 
much concerned about the results of that experience in enough 
cases as we are the fact that we can say there's something 
there. The worse thing we can have is not something--we still 
don't have something for a lot of people as we talked about, 
but our goal by this case-by-case monitoring and evaluation and 
reimbursement on the basis of effectiveness is to drive the 
system to produce better results for each individual, even if 
they're more intensive and involved, so that we have the 
ability to both see cost efficiencies, but also to see cost 
efficiencies that may involve much greater investment up front 
that actually works.
    Mr. Mica. Well, just--and I know my time is expired, but, 
again, I think we ought to look at something, because, folks, 
we're paying for this. Everybody says long term is the 
expensive. Well, you go back and look at these cases you're 
doing of 30 and 60, the short term, but you do 4 or 5 of them, 
and then the interlude disruption, the social disruption, 
they're out committing crime, they don't have a job, they're 
back in the system, and we're doing long-term, in effect, 
because most of them have three and four shots, and they're 
still addicted. And you add that up, and I'll bet it's less 
than the cost of a longer-term successful program. So at some 
point I think we've got to find some way to make this 
successful and what works being funded, at least from our 
Federal investment standpoint.
    Thank you. I yield back the balance of my time, Mr. 
Chairman.
    Mr. Souder. Thank you. We'll use it very wisely.
    I appreciate you all being here today and fielding the many 
questions and taking the time with us. I'm sure there will be 
many followups, and this is just the start of your adventures 
on the Hill, but we appreciate starting with your committee and 
thank you for your work, all three of you.
    With that, if Dr. Boyer-Patrick would come forward and 
remain standing.
    If you'll raise your right hand. As you heard, as an 
oversight committee, we take our witnesses under oath.
    [Witness sworn.]
    Mr. Souder. Let the record show the witness responded in 
the affirmative.
    Thank you for your patience. You get the opportunity to be 
the first one on Capitol Hill to respond to the Federal 
Government's initial proposal in the treatment programs. 
Welcome.

 STATEMENT OF JUDE BOYER-PATRICK, M.D., M.P.H., HAGERSTOWN, MD

    Dr. Boyer-Patrick. Thank you, Mr. Chairman, and good 
afternoon, and to the members of the subcommittee----
    Mr. Souder. Could you hold just a minute? The mic isn't on.
    Try it again.
    Dr. Boyer-Patrick. We'll start again.
    Good afternoon, Mr. Chairman, and members of the 
subcommittee, with a special hello to Ranking Member Elijah 
Cummings from my home State of Maryland. Thank you for inviting 
me to testify about the administration's new drug treatment 
voucher initiative.
    As an addiction specialist and a child adolescent 
psychiatrist at Brooklane Health Services, which is a 50-year-
old private nonprofit behavioral health program founded by the 
Mennonites in Hagerstown, MD, and the former medical director 
of an addiction program in Annapolis, MD, and a member of the 
Maryland Governor'S Drug and Alcohol Council, I have spent 
significant time thinking about how to expand and improve the 
drug and alcohol treatment system and maximize treatment 
options for my patients.
    Investing new funding in the treatment system is critical, 
because the treatment gap looms large, both in my State and 
nationwide. In Maryland there are approximately 250,000 
individuals who need drug and alcohol treatment, while 
nationwide that number is much larger.
    The administration through President Bush and drug czar 
John Walters have shown great leadership by proposing an 
additional $600 million in the drug and alcohol treatment 
system at a time when there are many competing priorities of 
national importance.
    However, while the drug treatment voucher program proposes 
significant additional funding, the program will require 
safeguards to ensure that it provides the most effective 
treatment in an efficient manner. These safeguards include 
ensuring that the voucher program supports evidence-based 
practice. The science of addiction medicine has greatly 
advanced during the last several years through genetic studies, 
brain imaging and medication development. It is important that 
the focus on evidence-based treatment continue, and that drug 
and alcohol treatment expansion helps to support access to this 
cutting-edge care, holding faith-based programs accountable to 
the same standards of care, performance and licensure 
certification as all other licensed or certified programs so 
that patients receive appropriate quality care for this medical 
condition. States must have the power to require uniform 
licensing or certification of all addiction treatment programs, 
including those provided by faith-based groups, to avert 
malpractice and maximize the life-saving power of these 
services, protecting States, local governments and drug and 
alcohol treatment providers against unfunded costs of the 
voucher program.
    Because the voucher program is a new program that will have 
separate administrative systems attached to it at the State, 
local government and treatment provider level, it is important 
that States, local governments and providers are able to use 
voucher grant or other Federal funding to pay for these costs. 
For example, it will be difficult for States, local governments 
and providers to pay for the tracking costs associated with the 
performance outcome component of the voucher proposal without 
voucher funding or other Federal technical assistance funding. 
Ensuring that providers receive payment for the treatment they 
provide, as referenced above, the voucher program proposes to 
track the outcomes of treatment to evaluate treatment programs.
    While evaluation and performance studies have long been 
part of the treatment system, and many providers, especially 
the ones in Maryland, are comfortable with this fact, I am 
greatly concerned about the voucher program's proposal to base 
payment for each patient's treatment on resulting outcomes. 
First, the time it takes to gather outcome data would create a 
significant delay in the time it would take to pay providers, 
and this day would harm most programs financially. Second, no 
other medical treatment bases payment for past services on 
outcomes. For example, physicians treating hypertension or 
diabetic patients also receive payment regardless of whether 
those patients take their medications, eat a proper diet, 
exercise, or modify their other health behavioral problems.
    Performance-based payment for previously provided treatment 
is inappropriate. Using performance measures to evaluate past 
performance as a way to manage future investments in the drug 
and alcohol treatment systems and its providers would be a 
better goal. Provide patients with real choices. The voucher 
program should require faith-based providers to clearly state 
that patients have the right to choose another provider, 
including secular medical model treatment providers before 
treatment should begin.
    Prohibition of diversion of substance abuse prevention and 
treatment block grant funds to the voucher programs and to 
ensure that the new funding expands drug and alcohol treatment 
in as many States as possible.
    Finally, I urge Congress to require that the 
administration, while developing the program, and States, while 
implementing the program, set up advisory councils to guide 
them through these efforts.
    In Maryland I have participated in the Maryland Drug and 
Alcohol Council and the Maryland Drug Treatment Task Force, 
where both have reshaped and guided Maryland's drug and alcohol 
treatment system by gathering expert advice as well as public 
input. Our system of care in Maryland has greatly improved as a 
result of this process.
    Expanding alcohol and drug treatment and prevention is 
critical. So many lives depend on these services. I hope that 
Congress and the administration will consider seriously the 
recommendations I have discussed today.
    Thank you for hearing my testimony, and I would request 
that my written remarks be added to the data. Thank you so 
much, and I'll be happy to answer any questions.
    [The prepared statement of Dr. Boyer-Patrick follows:]
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    Mr. Souder. I thank you for your testimony, and you've 
raised a number of difficult questions we're going to sort 
through, but let me start with your example on the terminally 
ill cancer patients is absurd.
    Dr. Boyer-Patrick. No. I didn't say terminally ill cancer. 
I said hypertension and diabetic-type patients.
    Mr. Souder. It says providers treating terminally ill 
cancer patients receive payment despite the fact that their 
patients will die. And the fact is, is that the fundamental 
question here is what is the point of drug treatment? In other 
words, if it is a curable--something that is curable, some of 
us would like to see that in other parts of health care as 
well, because we're very frustrated at the accountability in 
the bureaucracy. That's not to say individual programs haven't 
been effective, and we've all met people through them, but the 
fundamental fact that the industry has to look at is every 
single one of us on the street have met people who have been 
through seven, eight, nine programs, that the programs have 
reported--those same programs where I've talked to individuals 
have reported to us that based on science, that person is 
cured, and then they relapse.
    Some of the nonscience-based programs where I've met people 
who have been off cocaine for 20 years after Johns Hopkins 
Hospital in particular told me they could not do it, and they 
went off overnight, and they're still clean 20 years later. 
There is a problem, in my opinion, you need a balance between 
our science fact-based things and things that have been erected 
around the process that protects the existing providers who 
don't want to be held accountable. And I think that you've 
raised some fundamental questions. We can't turn that into a 
big scam. We don't want to undermine the existing structure, 
many of which already works, and at the same time we have to 
have some kind of what I would say helpful input from the 
existing provider community rather than an overreaction in 
saying, look, we don't want to be subjected to accountability.
    You're going to be subjected to accountability. The 
question is what is a fair way to do it? Some of it is process, 
and some of it is results, because like you pointed out, some 
people don't follow what you tell them to do. How can you lose 
all your funding if they don't follow what--on the other hand, 
there's got to be some measurement in a curable disease as 
opposed to an incurable disease, and it should be in other 
parts of health care as well. And I'd appreciate your response.
    Dr. Boyer-Patrick. I think that's a very complicated--thank 
you for sharing your thoughts, Mr. Chairman, and I guess 
working in the field for over 20 years, this is what I've 
noticed. And if I may use Mr. Cummings' reference to Cadillac 
versus Pinto. I think the big part of it is reaching a person 
when they're ready. As a provider, what I have noted--and I 
have to reference back to what you were talking about. This 
program is for people who do not have insurance, because those 
people with insurance usually get treatment, and that is not 
necessarily the case as we found in the State of Maryland. 
There are barriers to entry.
    My concern is when a person is ready for treatment. There 
are many reasons why people seek treatment. A lot of times 
people seek treatment because they're going to get kicked out 
of school, kicked out of home, their parents are tired of them, 
the boss is going to fire them, the wife is going to kick them 
out of the house. So there is a window of opportunity sometimes 
where a person wants to get that treatment and the treatment is 
not available because of lack of money for a majority of the 
people in the city of Baltimore or a lack of bed space. And the 
treatment facility that I worked at for 5 years, we had beds, 
and people had insurance, but they were not allowed to come in 
because of barriers to entry. And so we tried to make that more 
uniform.
    So there is no way to know, Mr. Chairman, when a person 
walks in the door, be it the Cadillac or the Pinto, whether 
this is the one that is going to make it, but we don't change 
our strategy because this one looks like this one is the one 
that is going to make it because when they walk out of the 
door, they have a good family background, a network in place, 
they've been sent to a group home, they've been sent to a long-
term residential.
    There are a number of reasons that have to come into the 
pie as to why a person will make it and a person won't. We 
don't have a crystal ball to determine that, but I will let you 
know that there are many wonderful treatment programs out there 
that have licensed excellent staffs and do good work, and yet 
it's still 50/50. It's like guessing which is going to be--if 
it's going to be a boy or a girl without using an ultrasound. 
We don't know when the person walks in the door, and I just 
feel that to judge a program based on whether the 10 people 
come in and 2 make it versus 9 does not mean that that 
therapist is not a good therapist.
    I guess that's sort of where I'm going with this.
    Mr. Souder. But that's the way the world works. I had a 
retail furniture store, and each person could give me an excuse 
why they didn't sell as much that week, but ultimately part of 
the accountability is results. And, yes, the customers walk in 
with different qualifications. Some have more money. Some of 
them are more interested that day in buying. There's an 
accountability process, and with a number of programs that I've 
visited, quite frankly, they have a 90 percent success rate, 
and they have harder cases, in urban San Antonio, in urban 
Chicago and other places like that, than many of the programs 
who say that they only get 50 percent success rate. And that is 
partly what we're trying to address here is some of these 
programs that are grassroots-based, who live in the 
neighborhoods, who daily respond and who hardly get payment, 
and some of them--I've met some programs in Boston and in other 
places where they don't even have health insurance for their 
staff, but because they're invested in their community, they 
don't meet all of the great criteria, but they're getting 
people cured. And that's part of what we're trying to figure 
out how to address.
    I don't mean to denigrate the advances of science or the 
passion and the commitment of the people in the existing 
system, but there's a mismatch here.
    Dr. Boyer-Patrick. Well, I would agree with you, Mr. 
Chairman, and if we could find out a way to make that match 
work, but at the same time you want outcomes, and you have to 
track outcomes, and you want everyone to be on the same playing 
field. I'm not saying that a program that is in the inner city 
or that is faith-based would be better suited to do the work 
that you want to do at a lower cost than the Cadillac program, 
who probably has a good program as well, but has lesser 
outcomes for whatever the variable is. My issue is that if 
you're going to require tracking outcomes, it should be on the 
same playing field. You can't hold someone to a higher or 
lesser level or standard.
    And so I'm not saying that the voucher program isn't a good 
program. I think it's a good way to meet the need for many 
people who do not have access to funds, but once they have that 
voucher, who is going to make that decision? Where are they 
going to go? To the Pinto, because it's better and cheaper? To 
the Cadillac, because there's a bed available? To long term 
because since my work is with children and adolescents, I know 
that with adolescents, because of their developmental level, 
they have no abstract thought, and they think that it's now or 
never, and it's not going to happen to me? Treatment for 
adolescents takes way longer than treatment for an adult who 
may have more hammers over their head, and they need to do it 
more. So we have less adolescent treatment. We don't have the 
time.
    Now, the reason why people are in and out and in and out, 
because that's managed care. I can guarantee you that there are 
many times we'd like to keep them longer, but we cannot keep 
our doors open if we can't get paid, and the system that is in 
place right now will not allow us to do it. So we do the best 
we can with the time we have. It's not a perfect system. But I 
think there are a lot of other parameters that have to be 
looked at before this is all said and done.
    Mr. Souder. And I think you've raised a very important 
question. There can be a double standard in accountability, and 
we have to work that through to be fair to all. Thank you.
    Mr. Cummings.
    Mr. Cummings. The discussion that you all just had is an 
issue that has been raised in this committee before and is an 
extremely complicated issue. One thing that you will find that 
I think we all share, Democrats and Republicans, is that we 
want our tax dollars to be spent effectively and efficiently, 
and I'm sure you share that.
    As I'm sitting here listening to your discussion with the 
chairman, I was thinking about how shaky drug addicts can be. 
I've often said that when I talk to--I've had relatives who 
were drug addicts, when I talk to them, I always would say to 
myself, I'm talking to a ghost of the person I knew. It's not 
the person I knew, because the person I knew wouldn't lie to 
me. The person I knew wouldn't cheat on me. The person I knew 
wouldn't take my lawn mower, say he's borrowing it, and then 
sell it to the nearest pawnshop.
    And I would guess that when we're trying to measure 
treatment--and I guess this is a point you were trying to 
make--I guess there are a lot of reasons why people may not be 
successful. If a person is that shaky, then--and somebody said 
it--I think it was Dr. Barthwell who said it a little earlier. 
If a person is that shaky, almost anything can throw them out 
of treatment. In other words, they could have been faking it 
from the very beginning. They could have been. If a mother 
says, I'm going to throw you out of the house if you don't get 
treatment, the kid goes in, gets treatment, something different 
happens in the household, the child feels that they can get out 
of the situation, then they may drop out of treatment. I don't 
know.
    But I guess what I'm trying to get to is how do we make 
sure--going to what the chairman said, how do we make sure as 
best we can that we're not being treated--that people are not 
gaming the system, I've been a very strong proponent of making 
sure the treatment--that we don't have shams, but on the other 
hand, we have all of this shakiness with regard to the patient, 
with regard to the circumstances that a doctor cannot control 
or a provider cannot control, where's the middle ground there?
    I read your statement. In the same paragraph it says, 
using--the last sentence, it says, using performance measures 
to evaluate past performance as a way to manage future 
investments in the drug and alcohol treatment system and its 
providers would be a better goal, but, I mean, what does that 
mean?
    Dr. Boyer-Patrick. Well, I'm trying to think of the best 
way to put it. I guess as a provider it's been difficult for me 
to address how do you know when it's for real. And it has been 
of great concern to me that the drug and alcohol problem is the 
only problem medically, and I think it's a medical problem, 
that is more held to you have one or two chances to get this 
right, or it's done. That's it. Two strikes, you're out; three 
strikes you're out. I've met people at Betty Ford who said it 
took nine times. When I said hypertension or diabetes, I look 
at substance abuse as a chronic illness, and sometimes you have 
your periods of crisis, and then you have a flare-up.
    I also look at it as tools. You come to me for 
hypertension, I give you the medication. I have no control over 
whether you're going to do what you need to do. We have an 
obesity problem in our children and adolescents in this 
country, and we talk to parents, don't do this, don't do that. 
They do it anyway, because we're dealing with human beings.
    But there seems to be so much more at stake, because 
there's a limited amount of money available, so what we say to 
a drug addict is, you've got this amount of time to get it 
right, and if you don't, then it's over.
    Are you going to have people who beat the system? You bet 
you. That's where all the research has been going into over the 
years over recontemplation and contemplation and readiness for 
treatment. If we can get the person at the right time in the 
right program, then we can probably have 100 percent success, 
but we're dealing with human beings here with a very, very 
difficult disease to treat, and the only reason why we keep at 
it is because we win sometimes.
    But there's no guarantee that we're going to win all the 
time, and I guess my concern is not that we try to help or give 
the opportunity to people who have never had it or to make beds 
available or payment available for someone on the first go-
round, but when do we end? It seems to be not until they decide 
it's over or they drop dead or--I mean, we've lost kids. I've 
lost kids who have overdosed on heroin a week or two after they 
have left my treatment center, in a bathtub at a friend's 
house, but I also have kids who are still clean and sober 
today, and the ones we thought would make it don't; and the 
ones we say don't have a chance do. There's no magic ball to 
it.
    But I understand that there's a finite amount of money, and 
that's the dilemma, and all I'm saying is that there are good, 
well-meaning treatment providers who give good services, but 
when I talk about substance abuse, Mr. Chairman, what I say is 
if you're ready, it doesn't matter what treatment service you 
go to, and if you're not ready, it doesn't matter what 
treatment service you go to. That's it in a nutshell.
    Mr. Cummings. We're going to talk about faith-based at 
another time, and this is not necessarily a faith-based 
question, but I think about--when I think about faith-based, 
you said something about trying--when setting the standards, 
making sure that there's certain components of the treatment, I 
guess, and a lot of--let me just finish this.
    My church has a drug treatment component, and we have some 
volunteers who do this in life. This is what they do. My church 
has 10,000 members, so we have some folks who can volunteer, 
come in and help out, but I think the main component of it is 
this self-help discussion. I don't know what you call that part 
of it, discussion piece. And then they also have the higher 
power element there.
    Dr. Boyer-Patrick. Twelve steps.
    Mr. Cummings. Right. And I take it that there is a clinical 
type of the treatment piece, and then there are other pieces 
that come to play with regard to that supportive--supporting 
each other, discussing the problem, situation.
    Dr. Boyer-Patrick. Mr. Cummings, there would be no way that 
a person in a community could even make it without those type 
of organizations.
    Mr. Cummings. Oh, I agree.
    Dr. Boyer-Patrick. Because, as a matter of fact, we highly 
recommend that if you go through a clinically based medical 
model-type treatment, that the people who have the greatest 
success are the ones who link up with those faith-based 
organizations. The very first Al-Anon meeting I attended 20 
years ago was in a Presbyterian church in California.
    Mr. Cummings. And the issue for us is not faith-based. A 
lot of us believe in faith-based. We're just trying to make 
sure--our issue is more of whether the faith-based organization 
will discriminate, not that the faith-based program is not 
important and plays a significant role.
    But this is what I want to get to. Do you see as you've 
read the material that you've read in regard to this effort, 
this recovery effort here that the drug czar was speaking 
about--what do you see the role of faith-based organizations 
being with regard to that voucher system? Are you following me?
    Dr. Boyer-Patrick. You know, I am, and I guess my concern 
was that this is a term that everyone is throwing out there, 
faith-based. I'm not always certain what that means. What I 
feel is if a person needs help--and not every person needs help 
on the same level. Some person might be using marijuana 
chronically, and we know that with some of the drugs, you don't 
need detox. But if a person walks in and needs detox and they 
get a voucher, if there is a good program for detoxification 
that is run by a secular or a faith-based, wherever there is a 
bed, that's where they need to go. A person might just need 
long-term partial, residential. It may be run by a secular 
organization or faith-based organization. Wherever there is 
availability, if the staff is credentialed, licensed, and there 
is a way of tracking outcomes, and they have a good program, to 
be quite frank with you, it doesn't matter to me if it's faith-
based or secular as long as the person needing the help gets 
the help they need.
    Mr. Cummings. The first part of what you just said is the 
piece I'm trying to get to. If it--and I'm trying to figure 
out, see, when I look at my church effort, I feel that that's 
more of a social----
    Dr. Boyer-Patrick. That is a support system.
    Mr. Cummings. Right. Right. On the other hand--but they do 
have some volunteer professional-type people.
    Dr. Boyer-Patrick. But if a person in Baltimore needs 
heroin detox, they're not going to go to your church first, 
because that's not where they're going to get the Buprenex. 
That's the point. So they still have to go someplace where they 
can get the detoxification services, and then you need the 
adjunctive services.
    So the question is what is the voucher going to cover, the 
adjunctive services or the acute services? And it depends on if 
it's alcohol, cocaine. Certainly with crack cocaine, you may 
not need detox, or marijuana you're not going to need detox, 
but if someone who is coming off of alcohol withdrawal goes to 
a faith-based organization that does not have the credentials 
to do detox, that person will die. That's the issue.
    Mr. Cummings. The voucher system, as I understand it, 
there's sort of an entry--there's an entry point where somebody 
does an evaluation, and in that evaluation process I assume 
that some type of treatment plan is put together. That's what 
would normally be done for almost anybody; is that right?
    Dr. Boyer-Patrick. That is correct, but so often, as we 
know in the city of Baltimore, which is where there is a great 
problem, with the majority of people being uninsured and they 
need services, they end up in the emergency room, and they go 
to places like the psychiatric floor to get what they need. 
Then they come out, and they don't get put into the adjunctive 
type of services that is going to assure success of recovery. 
You're just putting a Band-Aid on what the problem is.
    And so what is the voucher program going to do, just offer 
detox or offer a full continuum of care? And how much money are 
you going to spend for each time, and who's going to determine 
that?
    Mr. Cummings. Thank you.
    Mr. Souder. I think that you've raised a number of things, 
but it's really important to understand that there is an irony 
to the debate that we're going through, and I want to share a 
couple thoughts as we wind up this hearing, because we're going 
to be evolving this over the next year as we debate these 
different programs.
    Two friends of mine, Bob Whitson and Glen Lowery, got in an 
argument 15 years ago when I was a staffer on an elevator away 
from the general public, of which is probably the argument 
we're having here right now. Bob told Glen that he had become 
too establishment and was using data and science to masquerade 
a lot of the problems that were really human and psychological, 
and that Glen's approach was white establishment and he was 
buying into the way things did it, which excluded a lot of the 
grassroots programs which were actually most effective in the 
inner cities. Glen told Bob that he was too enamored of 
grassroots people who didn't necessarily want to have the same 
accountabilities as everybody else, and that while there was a 
truth to that, there needed to be some measurements.
    The irony here is that with President Bush's program and 
people like myself advocating this, most of these programs 
aren't going to be in our Republican districts. Most of the 
people who are seeking these grants that we're defending right 
now are grassroots organizations who predominantly are 
Democrats, who are predominantly in Democratic districts.
    I have looked at this for a long time, and I believe 
passionately that somewhere in here we've got to figure out 
this balance between people who come in and say, I can reach 
out and touch people and change their lives, but I don't know 
all of the science rigmarole, I don't have a college degree, 
but what I am is passionately involved with my neighbors, and I 
can get them off and move them, because you say a nonscientific 
thing, and that is when people want to get off, that's not 
scientific, and therefore some groups may be more effective 
than establishment centers at moving people to that first step.
    Furthermore, while there may be some health points, I 
grant, where the detox or the addiction has gotten so great 
that there's a physical endangerment, the truth is much of this 
is psychological, and that, in fact, I have talked to multiple 
heroin dealers and--addicts and coke addicts who went straight 
off and didn't get through detox and have been off for 20 
years. Now, the problem is that what makes some individuals 
able to do that and others not, and how do we have some kind of 
accountability standard that says, OK, you're able to do it 
here, but this person, when they try it, dies? And it's almost 
like what we've done is we have a risk-averse system that 
doesn't take some of the gambles with it, but we don't have 
some of the dramatic failures. But I feel, and many others, 
that we've missed these little grassroots organizations.
    I don't know whether the ranking member wants to go in with 
me, but I have threatened that--this is Bob Whitson's idea. 
I've threatened to put this in when I worked for Dan Coats. We 
stuck it in a couple of model bills, and that is a ZIP code 
test, because, you know, one of the most effective things is 
that if one-third of these dollars went to people who actually 
lived in the ZIP code of the people they are serving, maybe 
two-thirds, because part of this is that we get out of the 
neighborhoods where people are. When we look at these dramatic 
urban center programs, it's because the people are there. The 
problems just don't occur 9 to 5. They occur at night. The 
followup programs are there. They see the people in their 
neighborhoods.
    And the question is how do we get dollars into some of 
these programs that are in these areas that are people-based, 
that are active there, and much of which in the minority 
communities are oriented around the churches? How do we do 
that, and how do we meet the scientific advances? How do we be 
fair to those programs that have been working before that reach 
large populations, and they have other assets and strong 
families, and at the same time reach our high-risk populations 
that need a different approach, because quite frankly, it's not 
working overall in the urban centers, and we have some zones 
that are in danger of being left behind in America while the 
rest of America deals with it.
    And I don't believe there's some kind of malicious goal 
here to this treatment program or faith-based, that the goal 
here is to give it to Jerry Falwell and Pat Robertson. The goal 
here is to try to figure out how to advance the field. And it's 
not a political gimmick, because if it was, we'd be trying to 
give it to the suburbs, quite frankly, as Republicans, or rural 
areas. This is a different type of phenomenon, but it's going 
to be very difficult to work through, and I very much 
appreciate your passion and your years of dedication to it, and 
you've been a very articulate spokesman today, and I'm sure 
we'll hear from you in the future.
    Anything else you want to say in conclusion?
    Dr. Boyer-Patrick. In conclusion, what I wanted to say was 
you are absolutely right about the grassroots, and many of the 
grassroots are nonfaith-based, and many of them are. And I 
think it would be a mistake to just make the faith-based issue 
a big political issue. I think that there are many programs in 
the churches that do outstanding work, without which we could 
not be where we are today.
    So my only concern is that it was the drug czar who brought 
up the issue of measurement and outcomes, and a lot of these 
little faith-based programs that do good work don't have the 
money to do the measurement and outcomes, so how do you even 
know how good they are? And I'm saying if that's where you're 
going to go to determine who gets the money, make sure everyone 
is on the same playing field, because somebody might be doing 
good work, you just don't know about it. But I appreciate the 
opportunity to come here.
    Mr. Cummings. I just have one question, and I think the 
chairman raised a real excellent issue about how do you find in 
your field that faith-based organizations are often a major 
part of getting a person to that point, like he said, where 
they even want to do something about their problem? Do you find 
that to be the case?
    Dr. Boyer-Patrick. Yes. I find that to be the case, and not 
only that, but some of the faith-based organizations, some of 
them, because of the fact that they're not in the Federal loop 
or State loop, have private funders, and so there they might be 
able to offer more longer-term or different types of treatment 
that are not held to the same sort of standards. I think that 
the only concern is that you don't want a lot of people coming 
up just to try to get the money because they are faith-based, 
and I think that is what the big fear is, because we've had 
this problem before.
    But, yes, there are many good, effective programs out there 
that are faith-based, and many times the minister is the first 
person that the wife will call and say, you know, we have a 
problem at home. And that's where the entree is. But the issue 
is once you have that entree, to make sure that person gets to 
the right place for treatment, and when they come out, they 
have that network of services available to keep them clean and 
sober. There's no magic to it. It's hard work.
    Mr. Cummings. We really do appreciate you being here. Thank 
you.
    Dr. Boyer-Patrick. Thank you, Mr. Cummings.
    Mr. Souder. Thank you very much to all our witnesses today 
and to the Members who participated, and with that, our hearing 
is adjourned.
    [Whereupon, at 12:45 p.m., the subcommittee was adjourned.]
    [The prepared statements of Hon. Doug Ose and Hon. C.A. 
Dutch Ruppersberger, and additional information submitted for 
the hearing record follows:]
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