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





    ACCESS TO RECOVERY: IMPROVING PARTICIPATION AND ACCESS IN DRUG 
                               TREATMENT

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

                                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

                             SECOND SESSION

                               __________

                           SEPTEMBER 22, 2004

                               __________

                           Serial No. 108-269

                               __________

       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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                     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
TODD RUSSELL PLATTS, Pennsylvania    JOHN F. TIERNEY, Massachusetts
CHRIS CANNON, Utah                   WM. LACY CLAY, Missouri
ADAM H. PUTNAM, Florida              DIANE E. WATSON, California
EDWARD L. SCHROCK, Virginia          STEPHEN F. LYNCH, Massachusetts
JOHN J. DUNCAN, Jr., Tennessee       CHRIS VAN HOLLEN, Maryland
NATHAN DEAL, Georgia                 LINDA T. SANCHEZ, California
CANDICE S. MILLER, Michigan          C.A. ``DUTCH'' RUPPERSBERGER, 
TIM MURPHY, Pennsylvania                 Maryland
MICHAEL R. TURNER, Ohio              ELEANOR HOLMES NORTON, District of 
JOHN R. CARTER, Texas                    Columbia
MARSHA BLACKBURN, Tennessee          JIM COOPER, Tennessee
PATRICK J. TIBERI, Ohio              BETTY McCOLLUM, Minnesota
KATHERINE HARRIS, Florida                        ------
------ ------                        BERNARD SANDERS, Vermont 
                                         (Independent)

                    Melissa Wojciak, Staff Director
       David Marin, Deputy Staff Director/Communications Director
                      Rob Borden, Parliamentarian
                       Teresa Austin, Chief Clerk
          Phil Barnett, Minority Chief of Staff/Chief Counsel

   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
EDWARD L. SCHROCK, Virginia          C.A. ``DUTCH'' RUPPERSBERGER, 
JOHN R. CARTER, Texas                    Maryland
MARSHA BLACKBURN, Tennessee          ELEANOR HOLMES NORTON, District of 
PATRICK J. TIBERI, Ohio                  Columbia
                                     BETTY McCOLLUM, Minnesota

                               Ex Officio

TOM DAVIS, Virginia                  HENRY A. WAXMAN, California
                     J. Marc Wheat, Staff Director
                Roland Foster, Professional Staff Member
                           Malia Holst, Clerk
      Tony Haywood, Minority Professional Staff Member and Counsel


                            C O N T E N T S

                              ----------                              
                                                                   Page
Hearing held on September 22, 2004...............................     1
Statement of:
    Curie, Charles G., Administrator, Substance Abuse and Mental 
      Health Services Administration, Department of Health and 
      Human Services.............................................     6
    Heaps, Melody, president, Treatment Alternatives for Safe 
      Communities; and Dr. Michael Passi, associate director, 
      Department of Family and Community Services, city of 
      Albuquerque, NM............................................    22
Letters, statements, etc., submitted for the record by:
    Cummings, Hon. Elijah E., a Representative in Congress from 
      the State of Maryland, prepared statement of...............    50
    Curie, Charles G., Administrator, Substance Abuse and Mental 
      Health Services Administration, Department of Health and 
      Human Services, prepared statement of......................     9
    Heaps, Melody, president, Treatment Alternatives for Safe 
      Communities, prepared statement of.........................    25
    Passi, Dr. Michael, associate director, Department of Family 
      and Community Services, city of Albuquerque, NM, prepared 
      statement of...............................................    31
    Souder, Hon. Mark E., a Representative in Congress from the 
      State of Indiana, prepared statement of....................     4

 
    ACCESS TO RECOVERY: IMPROVING PARTICIPATION AND ACCESS IN DRUG 
                               TREATMENT

                              ----------                              


                     WEDNESDAY, SEPTEMBER 22, 2004

                  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 2 p.m., in 
room 2247, Rayburn House Office Building, Hon. Mark Souder 
(chairman of the subcommittee) presiding.
    Present: Representatives Souder, Cummings, Norton and 
Ruppersberger.
    Staff present: J. Marc Wheat, staff director; Roland 
Foster, professional staff member; Malia Holst, clerk; Tony 
Haywood, minority professional staff member; and Teresa Coufal; 
minority assistant clerk.
    Mr. Souder. The subcommittee will now come to order.
    Good afternoon and I thank you all for being here.
    Today, we will continue the subcommittee's examination of 
drug addiction treatment or as President Bush refers to it in 
the National Drug Control Strategy, healing America's drug 
users. It is estimated that at least 7 million people in the 
United States need substance abuse treatment. Providing 
treatment is important because it improves the lives of 
individuals and reduces social problems associated with 
substance abuse.
    Effective treatment, for example, reduces illegal drug use, 
criminal activity and other risky behaviors while improving 
physical and mental health. When tailored to the needs of the 
individual, addiction treatment is as effective as treatments 
for other illnesses such as diabetes, hypertension and asthma.
    Last year, President Bush took what I believe to be a very 
significant step toward assisting the difficult problem of 
extending help to those suffering from substance abuse when he 
unveiled the Access to Recovery Initiative. Beginning this year 
the President's initiative will provide $100 million to the 
Substance Abuse and Mental Health Services Administration to 
supplement existing treatment programs. This is intended to pay 
for substance abuse treatment for Americans seeking help but 
can't get it, many of whom cannot afford the cost of treatment 
and don't have insurance that covers it.
    If fully funded at $200 million per year as requested by 
the President, this program could help up to 100,000 or more 
suffering from addiction to receive treatment. The program also 
has enormous potential to open up Federal assistance to a much 
broader range of treatment providers than currently available 
today.
    The initiative will support and encourage a variety of 
treatment options and provide those seeking assistance a choice 
in treatment approaches and programs. Providing choices for 
those in need of assistance allows the individual to select the 
program that best addresses their personal needs. It has often 
been said that in order to help substance abusers, you need to 
meet them where they are. This approach goes a step further by 
allowing those seeking help to determine themselves where they 
want this meeting to occur and with whom.
    This new approach to treatment will establish a State-
managed program for substance abuse clinical treatment and 
recovery support services buildupon the following three 
principles.
    Consumer choice. The process of recovery is a personal one. 
Achieving recovery can take many pathways, physical, mental, 
emotional or spiritual. Given a selection of options, people in 
need of treatment for addiction and recovery support will be 
able to choose the programs and providers that will help them 
most. Increased choice protects individuals and encourages 
quality.
    Outcome oriented. Successfully measured by outcomes, 
principally abstinence from drugs and alcohol and including 
attainment of employment or enrollment in school, no 
involvement with the criminal justice system, stable housing, 
social support, access to care and retention and services.
    Increased capacity. The initial phase of the Access to 
Recovery will support treatment for approximately 50,000 people 
per year and expand the array of services available including 
medical detoxification, in-patient and out-patient treatment 
modalities, residential services, peer support, relapse 
prevention, haste management and other recovery support 
services. These funds will be awarded through a competitive 
grant process. States will have considerable flexibility in 
designing their approach and may target efforts to areas of 
greatest need to areas with a high degree of readiness or to 
specific populations including adolescents.
    The key to implementing the grant program is a State's 
ability to ensure genuine, free and independent client choice 
of eligible providers. States are encouraged to support any 
mixture of clinical treatment and recovery support services 
that can be expected to achieve the program's goal of cost 
effective, successful outcomes for the largest number of 
people.
    Today, we will learn more about the status and the goals of 
the Access to Recovery Initiative with the person most 
responsible for implementing it, my fellow Hoosier and friend, 
SAMHSA Administrator, Charles Curie. We will also hear from 
several experts who are on the front lines of substance abuse 
treatment. Melody Heaps is the president of Treatment 
Alternatives for Safe Communities in Chicago, IL, a recipient 
of Access to Recovery funding. Dr. Michael Passi is the 
associate director of the Department of Family and Community 
Services in Albuquerque, NM which was a pioneer in providing 
choices for those seeking substance abuse treatment.
    Thank you again for being here today and I look forward to 
hearing more about the Access to Recovery from our experts who 
are with us today.
    [The prepared statement of Hon. Mark E. Souder follows:]

    [GRAPHIC] [TIFF OMITTED] T8353.001
    
    [GRAPHIC] [TIFF OMITTED] T8353.002
    
    Mr. Souder. 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.
    I also ask unanimous consent that all exhibits, documents 
and other materials referred to by Members and the witnesses 
may be included in the hearing record and that all Members be 
permitted to revise and extend their remarks. Without 
objection, so ordered.
    [Witnesses sworn.]
    Mr. Souder. Once again, thank you for your patience and for 
your leadership not only here but in your previous State 
position in Pennsylvania in advocacy for those who often don't 
have advocates. You have been consistent for many years talking 
about co-occurring dependencies and creative ways to address 
these problems. Thank you for being here.

 STATEMENT OF CHARLES G. CURIE, ADMINISTRATOR, SUBSTANCE ABUSE 
AND MENTAL HEALTH SERVICES ADMINISTRATION, DEPARTMENT OF HEALTH 
                       AND HUMAN SERVICES

    Mr. Curie. Thank you so much, Mr. Chairman. It is great to 
see you again.
    I appreciate the opportunity to testify today. I also 
request that my written testimony be submitted for the record.
    Mr. Souder. So ordered.
    Mr. Curie. I am pleased, Mr. Chairman, that you and the 
committee have selected the President's Access to Recovery 
Substance Abuse Treatment Initiative as the topic of this 
hearing. Again, I am very pleased with your opening statement 
of support for the concept and for the program, Access to 
Recovery.
    It is also a privilege for me today to be participating in 
the same session with Dr. Michael Passi from Albuquerque which 
did pave the way with a voucher type of program and New Mexico 
happens to be one of the recipients of Access to Recovery, so 
we have high hopes for the implementation there. Also, my 
friend and colleague for whom I have such regard, Melody Heaps 
who has done so much on behalf of individuals trapped in 
addiction in the criminal justice system, bringing hope in her 
career.
    Expanding substance abuse treatment and capacity and 
recovery support services is a priority for this 
administration. There is a vast, unmet treatment need in 
America. Too many Americans who seek help for their substance 
abuse problem cannot find it. A recently released 2003 National 
Survey on Drug Use and Health, known as the Household Survey, 
provides the scope of the problem.
    In 2003, there were an estimated 22 million Americans who 
were struggling with a serious drug or alcohol problem. The 
survey contains another remarkable finding. The overwhelming 
majority, almost 95 percent of people with substance use 
problems, do not recognize their problem. Of those who 
recognize their problem, 273,000 reported that they made an 
effort but were unable to get treatment.
    To help those in need, SAMHSA supports and maintains State 
substance abuse treatment systems through the Substance Abuse 
Prevention and Treatment Block Grant. Our Targeted Capacity 
Expansion Grant Program continues to help us identify and 
address new and emerging trends in substance abuse treatment 
needs. Now, we also have Access to Recovery, ATR. It provides a 
third complementary grant mechanism to expand clinical 
treatment and recovery support service options to people in 
need.
    ATR was proposed by President Bush in his 2003 State of the 
Union Address. It is designed to accomplish three main 
objectives long held by the field, policymakers and 
legislators. First, it allows recovery to be pursued through 
many different and personal pathways. Second, it requires 
grantees to manage performance based on outcomes that 
demonstrate patient successes. Third, it will expand capacity 
by increasing the number and types of providers who deliver 
clinical treatment and/or recovery support services.
    The program uses vouchers and coupled with State 
flexibility and executive discretion, they offer an 
unparalleled opportunity to create profound positive change in 
substance abuse treatment financing and service delivery across 
the Nation.
    The uniqueness of ATR and its program is its direct 
empowerment of people, of consumers. Individuals will have the 
ability to choose the path best for them and the provider that 
best meets their needs whether physical, mental, emotional or 
spiritual. Recovery is a very personal process. If you were to 
ask 100 people about their story of recovery, people in 
recovery, you would get 100 different stories. There would be 
common elements but each would have their own pathway.
    ATR ensures that a full range of clinical treatment and 
recovery support services are available, including the 
transforming powers of faith. I had the privilege of joining 
the President in Dallas when he announced that $100 million in 
Access to Recovery grants were being awarded to 14 States and 1 
tribal organization. These first grantees were selected through 
a competitive grant review process that included 66 
applications submitted by 44 States and 22 tribes and 
territories.
    While all applicants had the opportunity to expand 
treatment options for different target population groups and 
utilized different treatment approaches, they all had to meet 
some specific common requirements, including the need to ensure 
genuine free and independent client choice of eligible 
providers and to report on common performance measures to 
illustrate effectiveness.
    Key to achieving our goal of expanding clinical substance 
abuse treatment capacity and recovery support services and 
successfully implementing ATR is the ability to report on 
meaningful outcomes. We are asking grantees to report on only 
seven outcome measures. These measures are recovery-based and 
broader than simply reporting numbers of people served or beds 
occupied. They get at real outcomes for real people.
    First and foremost is abstinence from drug use and alcohol 
abuse. Without that, recovery and a life in the community are 
impossible.
    Two other outcomes are increased access to services and 
increased retention and treatment related directly to the 
treatment process itself. The remaining four outcomes focus on 
sustaining treatment and recovery, including increased 
employment, return to school, vocational and education 
pursuits, decreased criminal justice involvement, increased 
stabilized housing and living conditions and increased supports 
from and connectiveness to the community.
    These measures are true measures of recovery. It is the 
first time we are striving to measure recovery in those terms. 
They measure whether our programs are helping people attain and 
sustain recovery. As a compassionate Nation, we cannot afford 
to lose this opportunity to offer hope to those fighting for 
their lives to attain and sustain recovery. Because the need is 
so great, the President has proposed in fiscal year 2005, to 
double the funding for Access to Recovery to $200 million and 
to also increase the Substance Abuse Prevention and Treatment 
Block Grant by $53 million for a total of $1.8 billion.
    As you know, the President's fiscal year 2005 budget is 
before Congress right now. The President's proposed substance 
abuse treatment initiatives are good public policy and a great 
investment of Federal dollars. As the President said, and we 
all know, our Nation is blessed with recovery programs that do 
amazing work. Our common ground is a shared understanding that 
treatment works and recovery is real. Now, it is our job to see 
to it that the resources are made available to connect people 
in need with people who provide the services.
    I also would like to recognize, in conclusion, Dr. Wesley 
Clark,who is with me today, who is the Director of the Center 
for Substance Abuse Treatment which is the center primarily 
responsible within SAMHSA for the implementation and carrying 
out of Access to Recovery.
    Thank you and I would be most pleased to answer any 
questions you may have.
    [The prepared statement of Mr. Curie follows:]

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    Mr. Souder. Thank you very much.
    In your testimony, you have four different ways you 
determined how people were going to get the grants: client 
choice, how clients will be assessed, acquire the supplement 
and no supplant, the poor, uncommon performance measurements. 
Were those all weighted equally? How did you sort through your 
applicants and if you can also add, did it matter whether they 
had prior experience with this, like you said Albuquerque did? 
And give us some feeling that this wasn't just darts at the 
board or something.
    Mr. Curie. That's a very good question. The peer review 
committee and the reviewers definitely took their jobs very 
seriously. We did give weighting according to what we expected 
with ATR. There was clear weighting given to the applicants who 
had to demonstrate and those who won awards had to demonstrate 
they did have an objective assessment process in place, that 
they did have the capacity to have an eligible provider list in 
a way of assuring that the providers were going to clearly 
increase capacity.
    They also needed to indicate and show how they were going 
to assure there was not going to be fraud and abuse for using 
vouchers. Using electronic voucher approaches by using 
electronic forms of vouchers has been a way of doing that in 
other programs. I think most of the applicants who won were 
able to demonstrate they could do that.
    Also, they had to demonstrate that the client would have 
choice based upon that assessment, that there was a clear link 
to the assessment and choice, that the assessment process was 
an objective one, that there was no conflict of interest in the 
assessment process and the providers they were able to select. 
They also then had to demonstrate and give competence to those 
reviewing, that they had the capacity to actually carry this 
out in a timely manner, in other words that they did have 
structures in place and would be able to implement this at 
least by early 2005 in terms of making the awards.
    Previous experience was definitey a consideration because 
that would also show capacity to be able to carry this off 
successfully. It is clear though that this is a new way of 
financing and delivering services, so there were very few 
examples across the country of voucher programs. Wisconsin, 
which also happened to win a grant, also had a voucher program 
in Milwaukee and a track record as well.
    Mr. Souder. They are 3 year grants?
    Mr. Curie. Three year grants, yes.
    Mr. Souder. Are the outcomes reported annually and do you 
have a monitoring system for that?
    Mr. Curie. Yes. We are looking for the outcomes to be 
reported more frequently than annually. We will be looking and 
the States will need to demonstrate that they are beginning to 
collect outcome information within the first year. Yes, States 
need to demonstrate a capacity and that they would be able to 
glean the outcome measures from eligible providers. That would 
be one of the things we would expect in order for a provider to 
continue to be an eligible provider, that they respond to those 
seven domains.
    Our role at SAMHSA through CSAT will be to monitor the 
States' overall performance and see to it that the States are 
holding those provides accountable.
    Mr. Souder. One of the frustrations of any Congressman who 
works at all with grant requests, or at least supports those 
who do grant requests, has not known precisely how the 
measurements are done and particularly if this is going to 
expand to more than the 50,000 to 100,000. Did you review with 
the applicants that you didn't choose how to put together 
better programs or do they have a way to look at how to do that 
in the next round? Will you continue as you look at the 
outcomes that you are getting, do you have ways to communicate 
to people who didn't even apply the first round what you are 
looking for and how to make this program reflective of things 
that don't work and do work?
    Mr. Curie. I believe the answer to each of those questions 
is yes. We do have with all of our grant programs and 
discretionary grant programs the ability for an applicant who 
did not receive an award to ask for feedback in terms of where 
did they fall short and they can examine what their particular 
score was. We do offer ongoing technical assistance.
    Just as we did in the very beginning with Access to 
Recovery, we held five technical assistance sessions and we had 
a great response to those TA sessions. One of those five was 
geared toward tribal organizations. I know we had over 100 
tribal organizations participating as well. I think most if not 
all of the 50 States participated in those TA sections.
    We would continue that process of outreach to encourage 
folks to apply. If we are in that position, it would be very 
good news because it means the $200 million was being 
appropriated but we would be prepared to do that to assue we 
are continuing to do outreach and expand.
    Mr. Souder. There isn't any casual way to say this. As we 
move into areas that are say somewhat tinged with controversy 
such as voucher programs, faith-based programs, new ways of 
doing things, I think complete and total transparency and 
openness about this becomes more critical, even in our 
traditional way.
    Normally we just respond when somebody asks for feedback. 
We need some sort of systematic way because this is big dollar 
business in drug treatment and many organizations are very 
concerned there is going to be a double standard for those of 
us who are conservative Republicans who have certain ideas 
about how this should be done, and may not hold quite the same 
rigid standards to some of the new groups coming in have been 
held to. I think it becomes critical to review with everybody 
maybe in a more systematic form like you did by targeting these 
different groups to also continue to do the reviews, make sure 
all the data becomes available.
    Like you say, a lot of these are new providers. They aren't 
going to do it necessarily as efficiently in the beginning, but 
there are different types of groups. Drug cohorts don't work as 
much as we would like them to work but they still work a whole 
lot better than other types of systems and broaden to new 
approaches.
    We have this in the Community Block Grant Initiatives under 
the bill that Congressman Portman and Sandra Levin did because 
that was one of the ones where I sat through the first 
presentation, the grant applications and some of the reviews 
and this is even more difficult than those.
    Do you have any comments on that? I know that is what you 
are driving toward but as you well know, doing this all the 
time, this is not without some stirring in the treatment 
community. We have to make sure they know how we are doing it 
and why and what is fair.
    Mr. Curie. I think your observations are accurate in this 
situation. Clearly, you always have with any grant process, 
especially when you are talking a total of $100 million and 
hopefully $200 million. It gains a lot of attention in the 
field, gains a lot of attention from the States and from tribal 
organizations. Just that in itself, there is a lot of emotion 
around because the field is, I think there is general 
agreement, underfunded. It is a lot of dollars, so people are 
very hopeful that they are able to apply and actually receive 
an award.
    Second, you are exactly right about this particular program 
with the innovation of trying to bring to a systemic level 
vouchers and choice along with expanding the provider base to 
include recovery support services for the first time in a clear 
way which also includes expansion of faith-based providers is a 
change for the field as well. That becomes frought with concern 
and questions being raised. I think the solution of 
transparency is exactly the right course to take, that as we 
implement ATR that we are transparent about the outcomes? How 
it is going? Do we need to make any mid-course corrections? Are 
there things we are learning?
    Also during the process of people who have applied, I heard 
you suggest perhaps we want to consider more of a global 
feedback overall that would not undercut the integrity of the 
competitive process of giving overall feedback of maybe where 
we saw applications of this type and things to keep in mind as 
we look ahead. We can certainly incorporate that into our 
technical assistance as we move forward.
    Mr. Souder. Paticularly since in this category, when you 
hire what we call here without meaning it in a derogatory term, 
a ``beltway bandit,'' in other words somebody who is trained in 
grants and works in a large organization, they will 
systematically do that. They will do that, go see who won, try 
to figure out how to do the exact adverb and adjective that got 
the grant of the winners.
    But if you are out in a much broader group of people who 
aren't used to writing grants and you are trying to bring new 
people into the system, they aren't probably going to have the 
same hired people to do that for them in trying to figure out 
precisely where they are off becomes more critical and 
basically helps drive the program.
    Also, I remember as one of the principles, batters learn by 
striking out. If a pitcher is going to throw them curve balls 
and they can't hit it, they had better learn how to hit a curve 
ball. Publishing what we learn from the first innovative people 
out there, what isn't working, is going to be important and to 
share that because it may be that your criteria from the first 
time may change but you have to be open in the process or you 
will have everybody gearing up to go in one direction and then 
find there is a shared learning experience.
    We have done a series of faith-based hearings around the 
country. We didn't do a lot on drug treatment because we are 
treating this as a separate thing, but you can't deal with 
homelessness, with job development, with social services, child 
abuse without winding up with drugs and alcohol mixed in here 
and there. One of the things that was interesting because we 
always had representatives from both sides, both pro and 
against faith-based direct funding, was in drug and alcohol 
treatment, the questioning of licensed, traditional type 
providers versus this difficult question of drugs and alcohol 
which you alluded to is also a spiritual, in many cases, not 
necessarily in the sense of Christian, but a person has to make 
some kind of decision that they are going to be cooperative and 
that some of the failure rate in drug treatment programs isn't 
actually the providers not doing things right, it is people are 
mandated in, their family put them in, they didn't make the 
internal commitment and therefore they can go through an 
effective program and not be changed because they didn't 
change.
    The irony here and one of the things we were hearing at the 
grassroots is sometimes the training may not be as high in some 
of these groups but the outcomes may be better because the 
person did a transforming or they were able to reach them in a 
different way, such that they dried out or got off of 
narcotics. Freddy Garcia is a classic example because he 
doesn't even do drug treatment but the people get off drugs. 
That clearly wouldn't be eligible under a Federal program but 
there are groups in between there that mix that and we heard 
that in at least three to four of the cities in which we did 
these hearings and the wide range of how to do this. It is an 
interesting thing when you are dealing with the psychology of 
drug treatment.
    Mr. Souder. Absolutely. In fact, clearly we expected States 
as they look at eligible providers, because that is really I 
think the key of what we are talking about here, that they 
ensure the eligible providers met public safety standards if 
they are going to be receiving dollars through the vouchers. 
Also if you hang out your shingle and call yourself a 
particular kind of treatment program, if there is a license for 
that, you have to engage that; and also there is a range of 
recovery support services for which there may not be a specific 
State license but again, in terms of public accountability, the 
States needing to maintain the list of eligible providers.
    Mr. Curie. You are absolutely correct. Whenever you begin 
opening that, especially in a field that has really worked hard 
over the past 40 years to gain certification, to gain 
credibility along with the other health care fields, mental 
health and other types of primary health care, it does raise 
questions and concerns. I think the challenge is how do we 
operationalize recovery from a public policy and public finance 
standpoint. That is really what we are striving to do for the 
first time because there are many pathways to recovery. So we 
need to be thinking about this as a continuum because there are 
people whose lives wouldn't have been saved if it wasn't for 
that licensed, residential program, they went through a medical 
detox, licensed residence, they attained sustained recovery and 
now they are on their own personal recovery plan as a result of 
that.
    There are others who have gone through a similar program 
and it wasn't until they engaged the faith-based program that 
recovery took hold but also I would say probably each of those 
experiences added to that person being able to attain recovery 
some day. So I think it is clear we need a robust continuum 
that is available and when you have a qualified assessment and 
then a choice involved, I think you begin to open more of those 
pathways and the common denominator among all of those types of 
providers is holding them accountable to outcome. If they are 
held accountable to outcomes that reflect recovery, we think 
therein lies the key for public accountability that we have not 
seen before.
    Mr. Souder. One of the problems we have in job training is 
cherry picking, for lack of a better word, that most people who 
go on unemployment, get off unemployment and the question is, 
those are the easy ones to do because probably they are going 
to get off anyway. What you are really dealing with is a 
temporary situation and you are trying to move it faster or at 
least claim credit as opposed to the long term dependency.
    It is a little less clear to me how you would do that here 
but I can think of a couple types of things. Did you look in 
your grant system to see whether any of them were taking harder 
types of cases, in other words a program that specialized in 
taking people who failed four times?
    Another thing would be in co-dependency, it is real 
interesting in Vancouver, British Columbia where we were 
looking at the heroin distribution, the needles and free heroin 
from the government, basically. One of the things that happened 
in downtown Vancouver is the areas where needles are 
distributed, people don't want to be and so the housing there 
tends to be the lowest income and people who used to be 
institutionalized are released in those areas. So all of a 
sudden they are exposed for the first time to illegal narcotics 
and you have this huge bump up in co-dependencies of people who 
have other problems and all of a sudden they are in a zone that 
becomes a drug zone.
    I don't know whether this would be geographic, whether this 
would be different people who have co-dependencies, whether it 
would be people who failed multiple programs before, but 
looking for the real hard programs that really take up a lot of 
our drug money. I am not saying we don't need drug treatment 
for people the first time because if you can catch them early, 
you don't get them late. On the other hand, it can give you a 
false sense if you say we want to prove this program works, we 
are only going to take the people we think we can get at, 
first-time offenders, parents are there, wife is there, 
supportive, or husband. That won't give us a good read either.
    Do you have a mix? Did you work to get that kind of mix?
    Mr. Curie. I am confident that we do have the mix. Again, 
we had another discretionary grant program we implemented over 
the past year or year and a half called Screening, Brief 
Intervention, Early Intervention Program, which is focused on 
those individuals who are considered the hard core, long term 
addict but catching them early. This program was not focused on 
that. In fact, this program is focused on individuals who have 
an addiction that is longer term. We are looking especially to 
hit that treatment gap with those people who are ready for 
service.
    I think when it comes to cherry picking, the key thing to 
keep in mind here is this is the first time the client picks 
the provider. The provider doesn't pick the client. If someone 
is issued a voucher based upon the assessment and if a provider 
continually turns down people who bring vouchers, first of all, 
they are going to lose out on revenue but second, they have 
every reason to accept that client because they are going to 
get paid.
    Second, that is what we are expecting the States to monitor 
in terms of provider performance. If a provider is consistently 
not working with the program, that would be reason not to keep 
them. I think there are some clear safeguards in there but I 
think fundamentally the objective assessment that is taking 
place without a conflict of interest, it is not the provider 
doing the assessing, and then a voucher being issued based on 
the client picking the provider. Again, the only way a provider 
could cherry pick is to refuse the client who comes with the 
voucher.
    Mr. Souder. Here really it is you monitoring the States to 
make sure that they and their eligibility standards aren't 
taking the easiest ones first exposed, stable families, middle 
and upper income groups, no co-dependencies.
    Mr. Curie. Correct, and the other thing that is very good 
about the Access to Recovery, if you look at a profile and I 
believe we submitted that to you, of the grants that have been 
awarded, you see many of them are hooked into drug courts, the 
criminal justice system, vulnerable populations, adolescent 
treatment, some very tough and challenging cases just out of 
the shoot. So by virtue of the populations, the high risk 
populations that States were able to choose, again, you are not 
talking necessarily about an easy clientele out of the shoot.
    Mr. Souder. I thank you for your testimony and willingness 
to come today. I wish I could say that the general public and 
Congress have become more sophisticated in this area but I 
think we are moving a little that way because after you put 
billions year after year and you hear numbers, it becomes a 
little bit like the old Vietnam days where you blow up the 
bridges and blow up more bridges and pretty soon you realize 
you blew up more bridges than there were to begin with. 
Sometimes in drug treatment and other things, it feels like you 
are pouring in all this money and yet the problem isn't going 
down or you put it into child abuse, put it into drug 
prevention in Colombia or wherever and we have to get more 
sophisticated in our measurement standards.
    When groups come in and say, oh, if we can just put it into 
this, we will get $17 for every dollar returned and yet the 
Government is broke and if we did that, we would be 17 times 
more broke probably. We need to realize there aren't instant 
solutions here. This is going to be difficult. It is like a 
drug court but if you can get 25 percent of the people deterred 
or clean most of the time, it is much better than what we had 
before. We have kind of oversold a lot of these things and I 
think Congress in trying to analyze the spending, if we can 
show both success but reasonable success with the harder risk 
groups and people who weren't able to get it, it may be easier 
to get the money in the appropriations bills. I would hope at 
least that we are getting more sophisticated with that so we 
can avoid what good does it do to put the Government money in 
anyway because we do it every year and the problem doesn't 
change. That is our challenge for those of us in oversight and 
your challenge in administration.
    Mr. Curie. Absolutely. I couldn't agree with you more. To 
be able to paint a picture of success that is based on real 
numbers I think will not only benefit us but benefit you in 
making those decisions, but most importantly, it is going to 
benefit those trapped in addiction.
    Mr. Souder. Thank you very much for coming today.
    Mr. Curie. Thank you.
    Mr. Souder. If our second panel could come forward: Melody 
Heaps, Treatment Alternatives for Safe Communities, Chicago, IL 
and Dr. Michael Passi, associate director, Department of Family 
and Community Services, city of Albuquerque, NM.
    [Witnesses sworn.]
    Mr. Souder. Thank you, Ms. Norton, for joining us. Would 
you like to do a statement before I start the second panel or 
wait until after they give their testimony?
    Ms. Norton. Mr. Chairman, the only statement I have is 
first to apologize that I have been delayed at another hearing 
and then to say how important I think this hearing is which is 
why I have run by. There is an introduction of a judge in the 
Senate I have to do.
    All across the country, I think the link between access to 
drug treatment and elimination of crime is absolute. In the 
District of Columbia, we have people waiting in line for as far 
as the eye can see. Mr. Chairman, as you may know, there are 
some hard line jurisdictions that have decided to go way beyond 
where the Federal Government has dared venture. You have hard 
line jurisdictions like California, the three strikes and you 
are out State which inaugurate the notion of diversion to drug 
treatment for people caught with small amounts for the first 
time. I don't know how that is working out. All I know is they 
found their criminal justice system was so overcrowded, so 
costly with people who are not classic felons or classic 
criminals, that they have decided, for all their law and order 
concerns and innovations, to try something new.
    I am interested in this hearing in particular and in what 
we in Federal Government can do to increase access to 
treatment, real tough treatment. There are all kinds of folks 
who claim to be able to treat addiction. I think treating 
addiction, Mr. Chairman, must be the most difficult thing in 
the world to do.
    We all know something about addiction. Along about 10 p.m., 
I need grapes and it is all I can do to keep from going down to 
get some grapes. I have a sweet tooth and if I didn't exercise, 
I am not telling you I have real self control when it comes to 
the sweet tooth, but if I didn't exercise and do a lot of other 
stuff, I think the sweet tooth would have taken hold of my body 
by now.
    Try then to analogize to somebody who, for whatever reason, 
has a tendency toward an addiction that is even more harmful 
and I think that, first of all, we can be more empathetic but 
then we know from our own experience that unless we fasten upon 
treatments that in fact say, there is something approaching 
carrot and stick that even the best treatment doesn't work, so 
I am here to be educated and thank you for this hearing, Mr. 
Chairman.
    Mr. Souder. Thank you for coming.
    We will start with Ms. Heaps.

 STATEMENTS OF MELODY HEAPS, PRESIDENT, TREATMENT ALTERNATIVES 
    FOR SAFE COMMUNITIES; AND DR. MICHAEL PASSI, ASSOCIATE 
DIRECTOR, DEPARTMENT OF FAMILY AND COMMUNITY SERVICES, CITY OF 
                        ALBUQUERQUE, NM

    Ms. Heaps. Thank you, Mr. Chairman and members of the 
committee.
    First of all, it is a real privilege to have been asked to 
testify on Access to Recovery. I particularly find it a 
privilege because I know the work that you, Mr. Chairman, have 
been doing to support treatment and particularly to look at the 
issues of reentry and the impact reentry for criminal justice 
clients is having on our communities. I applaud your work and 
applaud the work and interest of other members of the committee 
on this very, very serious, serious problem. Thank you so much.
    I am Melody Heaps, the founder and president of TASC Inc. 
TASC is a statewide, not for profit organization headquartered 
in Chicago. Our primary span of services involves linking drug-
involved individuals in the criminal justice system with 
community-based treatment and other services. In fact, by 
statute and administrative rule, we are the designated agent of 
the State to do so.
    We provide the initial screening and assessment to the 
court, we facilitate admittance into substance abuse treatment 
and we incorporate a hands-on approach to providing case 
management services through the utilization of community 
resources that support clients and help them navigate through 
their regular social service system toward recovery. We also 
work with individuals involved in the juvenile justice system, 
the child welfare system and the TANF system.
    I would like to talk to you today about Access to Recovery 
and how it is going in Illinois and how it is being applied, 
but I also want to talk more broadly about the implications of 
the program for people in recovery, for families and 
communities and for local, State and national drug policy. Like 
many States, Illinois continually grapples with the problems 
associated with drug use and crime. In our urban areas, we are 
among the worse in the Nation in terms of drug use by arrestees 
at between 70 and 80 percent. In addition, yesterday at a 
meeting with HIDA, we found out that Chicago ranks No. 1 in 
heroin deaths and in emergency admissions to hospitals for 
heroin. It is a ranking that does not bode well for our city.
    Cocaine and heroin constantly emerge as problems and the 
Cook County system alone, the largest of its kind in the 
country, processes upwards of 55,000 felony cases each year. 
Most of these involve drugs or drug-related crime. Forty 
percent of new admissions to Illinois prisons are for felony 
drug possession cases. Even despite a recent attempt, the 
opening of a 1,000 bed Sheridan treatment and reentry prison, 
the large majority of our criminal justice population needs 
drug treatment but does not get it.
    This is a population with a complex set of needs. In 
addition to drug use or addiction, some will have mental or 
physical health issues, some need housing, most need education 
and jobs, many have children in our welfare system and most of 
them will not be eligible for Medicaid or any other kind of 
private insurance.
    We know if we want to promote long term recovery, promote 
restoration of citizenship and productivity while at the same 
time reducing drug use and reducing crime, we have to address 
all of these issues. Addiction treatment may be core to the 
stability of individuals, but if any of these other concerns go 
unaddressed, their chances of returning to drug use and crime 
increases significantly.
    It was with this in mind that the State of Illinois in 
partnership with TASC decided to apply for the Access to 
Recovery funds to support service delivery to individuals 
sentenced to probation with demonstrable drug problems. We 
already have a number of programs in Illinois that have been 
addressing this. There are the Statewide TASC services, drug 
courts, intensive drug probation but the sheer volume of 
probationers, over 125,000 at any given time, means that only a 
fraction of those needing services will have access to them.
    Access to Recovery will predominantly target populations in 
Chicago and Cook County, two surrounding counties who aren't 
otherwise receiving services but we are also piloting it in 
some rural areas where the additional challenges like 
transportation, scarcity of providers are major barriers to 
successful service delivery. One of the key components of the 
Access to Recovery model is a comprehensive assessment and 
referral process. Any probationer that comes into our program 
will be assessed for needs in a wide array of behavioral and 
other social service areas. In fact, we are putting together 
what we call an assessment to develop a recovery capital index. 
What does the individual have in terms of his own capital? Does 
he have a home? Does he have a family? Do they have an 
education, so that we will be able to tell the degree of 
depletion of these resources in an individual?
    Obviously substance abuse is one area. So is mental and 
physical health, housing, education, job training, family and 
life skills. Once the assessment is complete, we identify 
qualified providers in the client's community and make 
referrals.
    From a service delivery perspective, Access to Recovery 
represents something that is rarely seen in publicly funded 
services of any kind. That is client choice. We know there are 
core services that a client in recovery will benefit from like 
individual and group counseling but we also know that every 
individual responds differently. If our goal is individual 
recovery, then our strategy must be to help the individual 
identify the programs and services in the community that will 
best help them achieve a place of stability.
    Some will benefit from a mentor relationship, some will 
benefit from services in a faith-based context that addresses 
their spiritual needs as well as their clinical needs. Access 
to Recovery is truly a revolution in service delivery because 
it allows and empowers clients to do what works best for them.
    In that regard, I do want to acknowledge the President, his 
vision, his promotion of and support for the expansion of 
treatment in our communities. I also want to acknowledge the 
leadership of the Department of Health and Human Services, 
Substance Abuse and Mental Health Services Administration, 
particularly SAMHSA Administrator, Charles Curie, for taking 
hold of that vision, conceptualizing recovery in the broadest 
and yet most personal sense and for pursuing innovative 
strategies like Access to Recovery.
    This initiative has stimulated growth and challenge in our 
field that would not otherwise have occurred with a simple 
increase in funding. I also acknowledge the work that the 
Center for Substance Abuse Treatment has done in developing the 
proposal and in helping implement this very important program 
under the leadership of Dr. Wesley Clark.
    Access to Recovery will bring funding to community 
organizations that might not otherwise have such. TASC has been 
operating in Illinois for over 30 years. One of the fundamental 
constructs of successful recovery has always been getting the 
community involved with the individual while the individual is 
getting involved in the community. Local providers understand 
local issues. They know strengths, weaknesses and potential 
challenges of reintegrating ex-offenders into their community. 
They are more culturally and socially aware and they understand 
the best circumstances that precipitated the drug use in the 
first place. When the client is involved in local programs, it 
creates a level of trust and comfort that may not exist if that 
same client were required to travel across town or in some 
instances, across the State.
    From a policy perspective, Access to Recovery is important 
because it breaks down all the traditionally disparate funding 
streams and focuses funding on one thing, recovery. Success is 
measured by how well you assist an individual in achieving a 
place of clinical and social stability. This sounds like common 
sense but a program of this size, scope and complexity would 
have been almost impossible under any other previous funding 
mechanism. This move toward recovery focused and client focused 
funding started several years ago when many of the major 
Federal departments pooled resources for the Coming Home 
initiative. Access to Recovery represents the natural evolution 
of that strategy and I applaud the decisionmakers who were able 
to accomplish such a major sea change in funding and policy 
strategy in so short a time.
    Additionally, because Access to Recovery is based on client 
choice, it will result in funding efficiencies we have never 
seen before. The right resources will be applied in the right 
intensity at the right time to the right people. The 
implications are huge. We will finally be able to start getting 
a handle on what we need as towns, States and as a Nation to 
turn the tide of drug use and drug crime.
    I believe that Access to Recovery is the start of an 
innovative, new approach to funding and providing recovery 
services, an approach that focuses on what we have always been 
about, a full continuum of services supporting recovery which 
leads to the restoration of individuals, families and their 
communities. Right now there are 14 locations around the 
country that over the next 3 years will be redefining what it 
means to provide treatment and recovery services in an 
effective and efficient way. This is a critical time and a 
critical issue.
    Thank you for your time and I would be happy to answer any 
questions.
    [The prepared statement of Ms. Heaps follows:]

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    [GRAPHIC] [TIFF OMITTED] T8353.011
    
    Mr. Souder. Thank you.
    Dr. Passi.
    Dr. Passi. Mr. Chairman, members of the committee, I am 
pleased to be here to speak on behalf of Access to Recovery. I 
am particularly pleased that CSAT found something worthy in 
what Albuquerque has been doing for the last several years and 
used our work to help shape the Access to Recovery program.
    Needless to say, we believe in the approach articulated in 
Access to Recovery. Having built a system like it using local 
funds that will approximate $4 million a year during the 
current fiscal year, we will invest more money locally in this 
treatment system even while we welcome the resources that will 
come to us from the Federal Government. We speak here about 
something to which we have made a major investment and are 
happy to share our experiences with you.
    The city of Albuquerque's system is based around two basic 
elements. First is unbiased assessment and referral using 
standardized instruments. The second is patient choice among 
qualified providers with subsidies available to those unable to 
meet the cost of care through a voucher system. Both these 
elements are tied together by an electronic management 
information system that facilitates assessment, referral, 
client tracking and billing and by treatment standards that 
assure quality treatment services.
    To assure unbiased assessment and referral, the city has 
separated assessment from the provision of substance abuse 
treatment. Albuquerque Metropolitan Central Intake is a 
specialized agency that provides professional assessment of 
patients presenting for problems related to substance abuse. 
The primary tool used for assessment is the well known and 
standardized Addiction Severity Index. We administer ASI in 
both English and Spanish to patients in the system. For 
adolescents, AMCI uses the Modified Adolescent Drug Diagnosis 
instrument, another well known and standardized assessment 
instrument.
    Based on the findings of the assessment, patients are 
referred to the treatment providers who are best able to meet 
their needs from within the city's provider network. This 
network currently consists of 20 different providers ranging 
from large public agencies to single sole practitioners. The 
network is open to any provider that wishes to join and agrees 
to comply with the city's clinical standards and reporting 
requirements. This means we welcome providers that are public 
and private, for profit and non-profit, secular and faith-based 
so long as they meet our clinical standards and are willing to 
accept our fees.
    Income eligible patients are issued a voucher. It is not a 
piece of paper, it is an electronic account effectively 
established for them, to assist with the cost of their 
treatment, if they need such assistance. They are also given 
referrals to those providers in the network that could offer 
the services that meet their particular diagnosis. The value of 
their voucher is determined by the level of care the patient 
requires. For example, vouchers for early intervention, brief 
therapy and education, are principally for people who don't 
have severe substance abuse problems and many of those are 
first-time DWI offenders referred to us through the local 
courts. That is capped at $390 per patient. For people with 
more severe problems, vouchers may reach $3,500.
    What have we gained from this system? First, we think we 
have a better managed system. We have vigorous controls of 
treatment related expenses. Authorized units of treatment are 
based on objective assessments of needs and billed accordingly. 
We buy what is needed and pay only for what we buy.
    This was not the case in our previous system built around 
cost reimbursement contracts with a small group of provider 
agencies that independently determined what a client needed. 
All too often in these cases, these were agencies whose 
principal tool was a hammer and for whom the clients' problems 
always looked like nails.
    Beyond better management, we believe that opening the 
system to a broader range of practitioners has increased the 
likelihood of matching patients to the treatment approach and 
treatment setting that best meets their needs and preferences. 
Rather than narrow options to a handful of publicly supported 
providers, we now offer a broader range of treatment approaches 
and treatment settings that gives a system substantially 
greater flexibility in meeting different needs.
    Most of the providers in the network moreover participate 
in the private market for treatment services and are not wholly 
dependent on the city for their financing. City-subsidized 
clients at a given agency in a recent 45 day period, I just 
picked one at random, ranged from one or two up to 165. The 
mean number of city-financed patients at an agency was 17.
    Offering clients genuine choice in selection of a provider 
appears to affect the process of treatment in a couple of 
important ways. First, there is some element of market 
discipline. The patient is free to change providers if he or 
she does not believe that their needs are being met. We 
actually have had relatively few patients electing to change 
providers in midstream but they are empowered to do so if they 
want to and that appears in some way that I haven't been able 
to establish by research to better engage them in the treatment 
process.
    Moreover, I think and more importantly, simply having 
choice from the outset makes the patient an active, empowered 
participant in the treatment process. They are not just routed 
there by government, they are required to commit at least that 
one initial act of choosing a provider.
    How does this affect their outcomes? I can't say we are 
getting better outcomes now with a differently managed system 
than we were before. The only reason I can't say that is 
because our data from the way we operated before was so bad 
that I have nothing to compare what we are getting now against. 
We do have methodologically valid data, however, to show that 
we are getting positive outcomes, reduction in drug and alcohol 
use, reduction in binge drinking, reduction stress, reduction 
in depression, reduction in anxiety through the treatment 
process.
    Shortly before ATR was launched, we in fact launched a 
similar initiative locally looking at domains of outcomes, 
establishing three at least that are similar to CSATs looking 
at sobriety, employment and criminal justice involvement. I 
don't have the data yet to report to you the results but 
initial outcome data looks positive for us. I think it is 
important that we all recognize that outcomes aren't driven by 
the way in which the system is managed alone. It is also 
dependent on the quality of the treatment services that are out 
there.
    Recognizing that, we have allocated about $200,000 a year 
in local general funds to support improving treatment to all of 
those 20 providers within the substance abuse system to try to 
increase their knowledge and skill in applying evidence-based 
treatment practices.
    That, members of the committee, is the Albuquerque system. 
I would be happy to answer any questions you have.
    [The prepared statement of Dr. Passi follows:]

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    Mr. Souder. Thank you.
    Let me make sure I understand precisely how this is 
working. Dr. Passi, you are in the city of Albuquerque and the 
State of New Mexico received a grant and then it went to your 
organization in the city of Albuquerque?
    Dr. Passi. Mr. Chairman, the Albuquerque system was 
developed using local funds prior to ATR. When CSAT was looking 
at designing ATR, our system was one that they looked at as a 
system that uses a voucher-based program in order to finance 
drug treatment. So we have been doing this for about 6 years, 
entirely with local funds.
    Mr. Souder. Have you received any Federal funds from this 
new program at this point, Access to Recovery?
    Dr. Passi. We are a partner with the State of New Mexico. 
We have not yet received funds. The funds have not been 
released to us as yet.
    Mr. Souder. Because New Mexico is listed as one of the 
recipients, when you say you are a partner, it means you will 
be one of the groups that most likely will receive funds from 
the State of New Mexico or are you designing the State of New 
Mexico program or a mix thereof?
    Dr. Passi. I think it is a mix thereof, Mr. Chairman.
    Mr. Souder. Because you do have experience with it, you are 
unusual. I understand that. I am just trying to figure out how 
it works.
    Dr. Passi. I believe the New Mexico State proposal to CSAT 
was to expand treatment in Albuquerque using funds and 
particularly in our case, we want to expand and support 
recovery activities in relationship to treatment. Moreover, we 
would work with the State to help other communities, namely 
Santa Fe, Las Cruces and one of the Indian Pueblo groups 
implement a system comparable to ours using our methods and our 
electronic processing systems.
    Mr. Souder. So the State grants can be used both for actual 
treatment for those who are addicted and for setting up 
programs?
    Dr. Passi. It will be necessary to do some work in setting 
up programs, I believe, in every one of these grants. In the 
case of New Mexico, I think we will be able to move more 
quickly because Albuquerque has a system in place with a web-
based way in which screening and assessment can be done and 
communicated to providers, a billing system whereby accounts 
can be created for patients and billing done.
    Mr. Souder. Ms. Heaps, the State of Illinois got a grant 
and then you were picked as one of their recipients?
    Ms. Heaps. The State of Illinois asked us to help them come 
together to design the program because we are a designated 
agent of the State working with the criminal justice system. 
The decision was made to target probationers within that 
system. So we sat down together to design the program.
    The funds come to the State of Illinois, a portion of which 
will come to us for the work we do, the diagnostic assessment, 
the referral to treatment, the case management and the 
information technology that will trigger vouchers. The State 
retains the dollars for the treatment and will through the 
electronic management system be funding the programs that do 
take our clients.
    Mr. Souder. And then in setting up the system, are you 
setting up predominantly for Chicago or for all of Illinois?
    Ms. Heaps. Because of the vast numbers we are dealing with 
and obviously limited resources, we targeted Cook County as the 
primary seat because of the vast numbers of probationers that 
are there. We also added two what is known as color counties 
which essentially are suburban/urban areas and then added some 
rural areas, two rural counties, so that we could see how this 
pilot would be were it to be expanded statewide.
    Mr. Souder. In a metro area as big as Chicago, individuals 
have vouchers, but how many providers would you guess there are 
in Chicago?
    Ms. Heaps. Around the State, there are 140 providers with 
about 462 sites. Probably at least three-fourths of those are 
within the Chicago metro community. We, as TASC, have developed 
a provider network with actually every one of the 140 licensed 
treatment providers and also have been working in terms of 
recovery with many of the faith-based and other institutions 
job programs that would help our clients in the past. So we 
have a network already in existence but it has not been 
systematized, it has not been fully funded and this gives us an 
opportunity to do so.
    Mr. Souder. In addition to those in the system trying to 
track new people, do you have a process for clearing them for 
approval to make sure they are adequately licensed?
    Ms. Heaps. Yes. We have a set of standards we developed 
with the State. They just be licensed and certified as 
treatment providers. If they are not direct treatment providers 
but perhaps recovery support people, do they have a license if 
they are treating people in terms of safe buildings, etc. Is it 
a corporation not an individual, do they have a sound fiscal 
mechanism, do they have a set of standards for providing the 
service they have, do they have experience in dealing with this 
population? In order to make sure of that, we will also have 
and are engaging now an orientation program, a training program 
for those providers that are not used to being more 
sophisticated perhaps as you were talking about earlier with 
Mr. Curie, in dealing with Federal funding. So we will have an 
ongoing training program actually facilitated by the addiction 
technology transfer centers that are a part of CSAT but are 
locally based.
    Mr. Souder. Before I yield to Ms. Norton, let me see if I 
can make one more kind of global picture or sense out of 
something. The sheer volume of probationers, you said over 
125,000 at any given time, not in the course of a year but at 
any given time?
    Ms. Heaps. Any given day, right.
    Mr. Souder. That is Chicago and Cook County or statewide?
    Ms. Heaps. It is statewide but 80,000 I believe are in Cook 
County.
    Mr. Souder. Of those 80,000 probationers, how many would 
you say are drug and alcohol related?
    Ms. Heaps. The research suggests that we are dealing with 
60 to 70 percent that have some issues.
    Mr. Souder. So 60,000, it looks like?
    Ms. Heaps. Exactly.
    Mr. Souder. So you have 60,000 people there. Do you know 
how many of the percentage of the mix of 80,000 are juvenile 
adults?
    Ms. Heaps. We are dealing with the adult population in that 
number. We are not dealing with the juvenile population. We 
will only be focusing on adults courts.
    Mr. Soder. So in your Chicago area program, you are only 
going to be dealing with adults?
    Ms. Heaps. Yes.
    Mr. Soder. And only dealing with adults on probation?
    Ms. Heaps. Yes, that is right.
    Mr. Soder. And only drug and alcohol?
    Ms. Heaps. That is right.
    Mr. Soder. So we are probably at around the 60,000 number?
    Ms. Heaps. Yes, 50,000 or 60,000.
    Mr. Soder. Do you have a criteria that the person has to 
have, as we talked about earlier, whether it is some risk or 
some ability to show an interest or is it that they are high 
risk? You are not going to have the dollars to do all 60,000?
    Ms. Heaps. No, we are not.
    Mr. Soder. If we were looking at 50,000 in the whole 
Nation, it is unlikely that you are going to get 60,000 in 
Chicago?
    Ms. Heaps. That is quite clear. Again, because we have been 
working with probation for so long and have been working with 
them in terms of their screening mechanisms, we are going to 
take advantage of what they do in terms of screens. We are 
going to use the idea of people want to volunteer for 
treatment. We are also going to be looking at probation initial 
screens that suggest there is some activity perhaps in 
probation compliance, perhaps the hard cases you were talking 
about that indicate this individual may have a serious drug 
problem. He then would be referred to us for a full diagnostic 
assessment and if found drug or alcohol addicted or abusing, 
move into the treatment of their choice.
    Mr. Souder. Thank you.
    Ms. Norton.
    Ms. Norton. Thank you, Mr. Chairman.
    Ms. Heaps, as I listened to you describe the licenses, I 
think I heard all kinds of licenses but I am not sure I heard 
any kind of license or certification for professional 
proficiency in treating people with drug or alcohol addiction. 
Is there any such certification of licensing in the State of 
Illinois attached to your program or to this particular program 
that is under review here today?
    Ms. Heaps. By administrative rule in the State of Illinois, 
all licensed programs must have certified addictions counselors 
and there is a certification training program and annual 
training they just comply with. So all licensed programs have 
individuals treating individuals who are certified in 
addictions counseling.
    Ms. Norton. Can programs that are not licensed get the 
funding that is under discussion today?
    Ms. Heaps. Absolutely. We estimate that programs that are 
not licensed, programs that will do the recovery support, 
whether it is the spiritual counseling or the jobs or 
education, who will not or may not be licensed as a treatment 
program will, through our program, be able to get support, will 
be able to get the voucher paid for their services. We will do 
so based on a set of standards that I was talking about, 
bringing them in for training and orientation. In a mechanism, 
we are projecting that by the end of the second year, almost 40 
to 50 percent of the dollars will be going to other recovery 
support service programs, not simply licensed treatment 
programs.
    Ms. Norton. I tell you what, Ms. Heaps, I am very fortunate 
with my children. If I had a son or a daughter who had an 
alcohol or drug problem, one of the first things I would look 
to would be to see the level of professional proficiency. I 
raise this only because I look at the series of things that HER 
uses, those are the things you look to, abstinence I don't know 
for how long, stable housing, social connectiveness. I am very 
troubled by programs that are unlicensed or uncertified, very 
frankly, because I see them all around. They hover around these 
communities. The communities that have the greatest drug 
addiction have all kinds of programs springing up with people 
who are just like me, they don't know anything except they 
claim to have the ability to treat people with what I regard as 
the hardest of all things to treat. Give me cancer or heart 
disease, the causal relationship I think has worked out there 
better than an addiction.
    I just want to indicate my skepticism not of what you are 
doing but of the very idea and I speak from seeing the programs 
that abound. For example, if any religious program can get 
money, I happen to know that people who are most affiliated 
with a church are most likely to be able to be drug free. We 
have many ministers who have mentoring programs here quite 
unrelated to whether the Federal Government has dollars to hand 
out or not because they understand the relationship between 
faith and drawing people from addiction. Alcoholics Anonymous, 
for example, has often been faith-based.
    I have been very troubled by some of these folks who claim 
to be able to meet standards like this, particularly since the 
standards see so amorphous. I just want to indicate that 
skepticism here because these programs have grown up so often 
in the African-American community and it is very easy, 
particularly if you are a religious-based program, to show a 
tiny group of folks who were affiliated with your church or who 
you can show in fact met these standards. So much for that.
    The most of those affiliated with your two programs come 
out of the criminal justice system. Do most of them in one 
fashion or another have some contact with the criminal justice 
system?
    Dr. Passi. Representative Norton, about 60 percent of the 
patients that flow through Albuquerque Metropolitan Central 
Intake are referred to it from the criminal justice system.
    Ms. Norton. About 60 percent?
    Dr. Passi. The other 40 percent are self-referred or come 
from other referral sources.
    Ms. Heaps. Under our program, it will be 100 percent. They 
will be under the jurisdiction of the probation department 
coming to our program.
    I concur with your concern that drug treatment be delivered 
by licensed professionals and I think the State of Illinois 
worked very hard to make sure and has a very rigorous licensure 
program in place. So we are using them for treatment but we 
also recognize that we are dealing now with partnerships and 
that there are job programs, faith-based organizations out 
there that need to welcome these individuals in the community 
and surround them with support.
    Ms. Norton. That is very good if you are a job program but 
if you are in the business of helping people free themselves 
from addiction, you are in a very tough business and I think 
you have to be able to show some proficiency. The standard I 
use for the people in poor communities is the standard I use 
for my son and I don't see that as the standard if people can 
get government money who don't have that kind of professional 
proficiency.
    Your 60 percent and your 100 percent also tells me that the 
best way, which I think is very typical, to get drug abuse or 
alcohol abuse treatment is to knock somebody in the head or 
commit a crime. I just think we have to face that. There are 
all kinds of folks waiting in line saying catch me before I 
kill. I know I am a crack head. In fact, if you are virtually 
possessed with this addiction, the notion of having to go to 
jail first is very troublesome. I don't know what to do with 
that except that they are waiting in line. We can get hold of 
them but we are not doing that.
    I would like to know, finally, your evaluation of drug 
courts and what you know about drug courts. That is not a 
choice exactly. We have one here that is very successful. It is 
a kind of choice because you do choose to deal with your 
addiction and the crime that may be associated with it or you 
have made another choice, the choice to go through the 
traditional criminal justice system. I wonder what you think of 
that choice, the drug court or if there are drug courts in your 
jurisdiction with which you are familiar?
    Ms. Heaps. Yes, Representative Norton. In fact, we run six 
drug courts in the State of Illinois or are affiliated with 
them. TASC is a precursor to drug courts. It was set up in the 
early 1970's to be a sentencing alternative to incarceration 
for individuals involved with drugs. So much of the drug court 
protocols emerged from what had been TASC protocols but 
concentrated now on an individual courtroom where case 
processing of drug cases were to alleviate much of the 
overwhelming drug cases that were coming into the justice 
system practically shutting it down.
    Our experience in the criminal justice system as a leverage 
for successful outcomes I think follows what research was done 
particularly by UCLA which because we know addiction is a 
disease of denial, when the choice is treatment or jail, and 
the individual not always, not always chooses treatment, I 
can't tell you the number of our clients who would rather go to 
jail knowing they will get out in 4 to 6 months or maybe a year 
rather than go into treatment where if they fail, the 
consequences will be severe. People are more likely to succeed, 
be retained in treatment if there is some jurisdictional hammer 
as it were over their head. So drug courts can be a very 
effective mechanism for moving people into recovery and 
retaining them in treatment. We know that the longer you can 
retain an individual in treatment, the better chances for 
recovery.
    Dr. Passi. Our experience in Albuquerque has been similar. 
We do have a drug court and in fact we worked closely with the 
local district court in establishing their treatment protocols. 
All evidence is as Ms. Heaps suggests that for a certain 
portion of the criminal population, this is an effective way 
for us to get them into treatment and second, to retain them in 
treatment.
    Ms. Norton. I will just say in closing, Mr. Chairman, I 
think both of you have indeed targeted the group I am talking 
about. We can't get to most people ahead of time. It is naive 
to think when we don't get to people that all you have to do is 
arrest them and that will deal with it.
    I have been very impressed by what judges have said about 
the effectiveness of drug courts. I very much endorse the 
notion of choice. I think the first choice you have to make in 
order to free yourself from addiction is that you want to do 
it. That is kind of the ABCs of how to proceed. That is why so 
many people don't make it time and time again. Of course if you 
make that decision and you have a choice and you find a 
particular program that suits you, that would be even better.
    I suppose I am most concerned with the place, and Chicago 
would know all about this, where addiction almost comes 
naturally because you are in neighborhoods where people are 
surrounded by addicted people, by the selling of drugs, and if 
we know that is going to be the case, it does seem to me that 
we have to face the fact that once that first drug related 
crime is committed, we have a magic opportunity to get hold of 
that person in a carrot and stick way and therefore that the 
drug court may be one of the best approaches or devices that we 
have been able to use at least for those who are most likely to 
come in contact with the worse kind of addiction.
    I do note and was fascinated, Dr. Passi, that you said 
alcohol addiction was more prevalent in your program than drug 
addiction. So all these things have to be very much tailored to 
the jurisdiction.
    Thank you, Mr. Chairman.
    Dr. Passi. Multiple addictions really are increasingly the 
character of the patients that we see. They may be present for 
alcohol abuse but subsequent analysis I think shows that most 
people use a fair panoply of chemical substances from time to 
time or on an ongoing basis.
    Ms. Norton. Mr. Chairman, not only with grapes but grapes, 
ice cream and cookies. [Laughter.]
    Mr. Souder. We have been joined by Mr. Ruppersberger as 
well as our distinguished ranking member, Mr. Cummings. I will 
yield next to Mr. Ruppersberger.
    Mr. Ruppersberger. Thank you.
    Sorry, it seems we had a lot of hearings at the same time 
today, so if I ask a question that has already been asked, let 
me know.
    First, if specific services are not available in one area, 
are patients allowed to be transferred to other areas or even 
other States under the program?
    Ms. Heaps. Not other States, but certainly in the city of 
Chicago, other areas and maybe in the instance of the color 
counties or the rural counties, we would be able to allow them 
to access services in another area, yes.
    Mr. Ruppersberger. As far as the actual patient, drug 
addiction is an ongoing battle. If a patient fails in one area 
or regimen of a treatment, does that mean that it is a one shot 
deal or can they be involved and stay in the program until they 
get what they think they need?
    Ms. Heaps. I believe there will be different answers 
because of the nature of our population. In the instance of our 
population, which is under the jurisdiction of the probation 
department, if an individual fails in treatment, doesn't comply 
with what the court or probation order says, then through a 
case management conference with probation, TASC and treatment, 
we will look at the individual and say, can this person benefit 
from a different treatment, from a different placement? We may 
try that but if the probation office says we think this person 
is a threat to the community, we may not be able to offer them 
a second chance.
    We at TASC have consistently tried to offer people second 
chances, particularly looking at their case and what may need 
to be modification of the initial treatment. We would hope to 
be able to give them a second chance as long as we are not 
jeopardizing community safety in doing so.
    Dr. Passi. In Albuquerque, we presume that substance abuse 
is a chronic and a recurring illness and that patients are 
highly likely to have one or more relapses in the course of 
their recovery. How that might affect their relationship with 
the criminal justice system has to be dealt with differently 
than how it affects the relationship to the treatment system. 
Rather like those cigarette ads you see on the Metro in 
Washington, DC, don't stop quitting, I believe that we would 
welcome patients back into the system again and again.
    Mr. Ruppersberger. I am going to get a little parochial and 
I know you are from different States. I represent, along with 
Congressman Cummings, the Baltimore metropolitan area and 
Baltimore City. We do have a serious problem as does Chicago 
and other areas. It is my understanding that our State has not 
either made application to get the moneys that are available 
for these programs. What suggestions would you have for the 
State of Maryland or any State that really hasn't taken 
advantage of this program to move forward and to get the 
benefits?
    Ms. Heaps. That is a very good question. Knowing a little 
bit about the work that Maryland has done. Maryland has a drug 
court, I believe, and you have had TASC programs. So obviously 
from my standpoint, the first thing is to look at the client 
population that does not now have access to treatment and 
decide where and how you will isolate that population and give 
them access. Do you want to move criminal clients into 
treatment, do you want to make it broader, what level of 
treatment do you have in the community if you do make it 
broader?
    It seems to me that the State needs to partner with local 
or statewide private agencies as Illinois did with us to 
conceptualize the system and designing the system so that you 
might be able to apply next year. I am surprised, quite 
frankly, that Maryland did not apply. It would seem to me it is 
a classic case, much like Chicago is, and that some of the same 
decisionmaking processes would be potentially successful given 
your experience, given the breadth of your treatment, and given 
the fact that I know Baltimore has worked on this issue before. 
Hopefully you would be able to do so and I would be happy to 
talk with anyone in Maryland or the city.
    Mr. Ruppersberger. That is good and we might followup.
    If you were to go somewhere to get involved in this program 
for the State of Maryland and Baltimore, if you were me, where 
would you go, to the Governor, to the Mayor? What I am trying 
to find out is how we get started because there are a lot of 
resources here that may be very useful.
    Ms. Heaps. The State must apply for these grants. So it is 
the State, the Governor's office that must do the application, 
submit the application. Obviously the Governor's office has to 
work with your single State agency for substance abuse and 
potentially with leading providers in the community and/or 
criminal justice system.
    Mr. Ruppersberger. So the mayor?
    Ms. Heaps. Yes.
    Dr. Passi. I would echo that and I would say the city of 
Albuquerque has had a fairly good relationship with the 
Baltimore substance abuse systems since the time we were both 
target cities under CSAT. I believe that Baltimore has in place 
the basic structure to make an ATR system work. I think it is a 
matter of getting the Governor together with the mayor and 
utilizing what I at least the last time I was looking at it was 
a very strong structure. It may have simply been a choice to 
wait as some States did.
    Mr. Ruppersberger. For what reason?
    Dr. Passi. That the commitment to just building one of 
these systems is fairly major and I know there are some States 
that have elected to wait for an additional round of funding to 
see what happens with the initial grantees. Indeed, the manager 
of our system could not be here today because she is in Utah 
working with the State of Utah to assist them in preparing an 
application for a future round.
    Mr. Ruppersberger. Just one more question because my time 
is up. It is my understanding that Maryland did apply, did not 
get the grant, so if that is the case, what happened, not 
Maryland but generally. When States are not given the grant, 
what is the reason?
    Ms. Heaps. I can answer that to some extent because I am a 
member of the Center for Substance Abuse Treatment Advisory 
Council. Because of this grant, all advisory council members 
must vote on applications that come into the center. Access to 
Recovery was one. Because we were part of an application, I had 
to recuse myself.
    However, in the previous testimony by Mr. Curie and from 
what I understand, there was a peer review committee that 
ranked the proposals according to proficiency, identification 
of the population, the ability to develop an independent 
voucher system, information system, the ability to show you 
have a large network of providers out there, both licensed 
treatment providers and other recovery support providers. So 
there are a series of standards which I think are objective and 
you could easily obtain through the Center for Substance Abuse 
Treatment.
    Mr. Ruppersberger. Does the State put in the application or 
the city?
    Ms. Heaps. The State of Maryland would.
    Mr. Ruppersberger. Thank you.
    Mr. Souder. Thank you.
    I will now yield to our distinguished ranking member, Mr. 
Cummings.
    Mr. Cummings. First of all, thank you all for being here 
and thank you, Mr. Chairman, for calling the hearing. I am 
going to be very brief. Because of another meeting I did not 
get here earlier.
    I am interested in data collection. One of the things Ms. 
Norton was alluding to was how these folks pop up and I just 
think whenever government has money to give out, there is going 
to always be some persons or entities that pop up and decide 
that they want to be a part of the process and sometimes they 
are not qualified.
    I agree with Ms. Norton and I know you agree with her too 
that drug addiction is a very, very, very tough thing to deal 
with. I have seen in my district in Baltimore people who have 
been off for 15 years, clean, go back. I have also seen 
something that is of great concern and that is that the people 
who are out there, the recovering addicts, they know the good 
programs which is interesting. They will tell you in a minute 
which programs are I don't want to say fraudulent, but that 
aren't effective.
    I am just wondering, is data collection a real challenge 
for you and how do you measure the progress? You may have 
answered this earlier but it is something that is very 
important to us because we spend a lot of time in this 
subcommittee trying to address the issue of effectiveness and 
efficiency with regard to treatment and of course, the spending 
of Federal dollars. What happens is I think it is criminal to 
put somebody through a program that is not a program that 
effectively deals with them, then they go through a process, 
they are not in a position for maximum potential for recovery 
and then they go back on the street. The next thing you know, 
they sometimes end up worse off than they would have been if 
they had never entered the program because they are so 
frustrated and they have been bamboozled. I am just wondering 
how do you address those issues?
    Ms. Heaps. Again, both of us probably have very similar and 
a little disparate ways of doing it. In the instance of our 
program, we have an information system and a hands-on case 
management system that will track a number of things. Did the 
client show up for treatment, does the client comply with 
treatment? We will be in the program checking the client files, 
meeting with the counselor, recording that and that then gets 
played into an information system data base which gets reported 
to the State and gets fed back to the treatment provider and 
the client, by the way. It is important that the client see 
what their record and compliance is.
    There are on top of that the outcomes that have to be 
measured as a part both of the Federal program but even if the 
Federal program weren't there, there are outcomes we have 
always measured in terms of is the client complying with 
treatment, are they moving in treatment, are they drug free, is 
their status drug free, are they looking or is there a stable 
living arrangement, is there family or social engagement, do 
they have education or a job, are they crime free? So there are 
a series of outcomes which are frankly not rocket science. They 
are basic to what we know it means to be a citizen in our 
communities. Those outcomes are applied to every individual 
case, the data is collected, it is again transmitted to the 
various parties.
    In addition, there are data required that look to do 
treatment providers open their doors, do the individuals have 
access to treatment, what is the number of treatment providers, 
who is licensed to do the treatment versus who is a recovering 
support service in Illinois' system? The money that will go to 
licensed providers and to recovery support services will be 
tracked again with hands-on case management and data 
collection. So we will know very, very detailed, per case what 
is happening in that individual's recovery.
    To the issue that has been raised and you raised again, it 
is true that money can bring a lot of folks to the table, many 
of whom really have a client's recovery in mind and many of 
whom do not but I think each of us has had to set up standards 
for participation in this program. I have a list here which I 
would be happy to provide for you, a faith-based organization 
that has had experience in the community, that is a legitimate 
organization that knows how to handle the population can offer 
the kinds of support and services that are critical to support 
recovery.
    Dr. Passi. We are getting pretty good at tracking process. 
Our system works really well at making sure we are getting what 
we pay for and we are paying for what we need according to an 
assessment instrument, but I think you are looking beyond that 
and that is where I think CSAT is making remarkable strides 
with the ATR program. That is to say, let us just stop 
measuring process, let us start measuring outcomes. I think the 
domains that they lay out, abstinence, employment, crime and 
criminal justice, family living conditions and social support 
are really the things that we have to start measuring and that 
we can measure. It is not real easy. There are some problems 
that we have run into in measuring criminal justice 
involvement. You can't rely solely on self report obviously and 
matching records from the criminal justice system with patients 
in the treatment system and confidentiality issues that get in 
the way but those issues are overcomeable.
    I now believe we are making major strides toward being able 
to say is patient X abstinent for a month, a year, 5 years 
after treatment; are they not arrested; are they arrested once; 
are they arrested weekly; did they get a job, did they not get 
a job; did they get housing or are they on the street? Those 
are the things ultimately that I think the addiction treatment 
system is aiming to affect. We are not simply in the business 
of providing treatment, we are in the business of buying 
abstinence, of buying employability, of buying recovery, I 
think is the concept that goes with it. Those are objective 
things, things that can be measured and those are things that 
we should be measuring.
    The city of Albuquerque started that before ATR in baby 
steps. We think ATR will push us to look at all of those 
domains, measure those domains and ultimately reward 
practitioners for their ability to produce positive outcomes in 
those domains.
    Mr. Cummings. Before I came to Congress, I was in the State 
Legislature and I also practiced law. A group of mainly 
gentlemen in my neighborhood, professional men, got together 
voluntarily and worked with a lot of people who were coming out 
of our boot camp program on Saturdays in a self help program, 
and didn't get a dime from the government. I looked at one of 
these evidence-based domains, social connectiveness. I don't 
know exactly what that means and I am sure you will tell me.
    We did this program for about 3 years and we noticed there 
were people who were socially connected but they were connected 
to the same people that sent them to prison. I can tell you one 
of the things we noticed too was the people who found a whole 
new set of friends and/or reoriented themselves toward loving 
their family, it may have been a child, it may have been a 
wife, they may get married or something like that, those were 
the guys I see on the street today who never went back.
    A lot of this was drug related, things they had been in 
boot camp for. They never went back and were living productive 
lives and almost everybody who went back to the social group 
they were from are back in prison and usually have committed 
much more serious offenses.
    When we talk about social connectiveness, what does that 
mean? Does that mean going to church?
    Ms. Heaps. You actually, I think, defined it yourself. This 
idea of family, getting back with a child, reinvolvement with 
the family, going to church, going to peer support, AA, Winners 
Circle, a number of communities. We aren't talking about social 
connectiveness going back to the gang. We are talking about 
changing perhaps patterns of social connectiveness that are 
constructive, that are supportive, that are healthy. That we 
have to look at and there are ways to be doing that. That is 
where I think faith-based organizations have a huge role in 
this. In some of our communities, they are the only 
institutions, especially for people in some of our communities 
with huge reentry. I think the faith-based community has a 
wonderful role in helping develop social connectiveness.
    Mr. Cummings. You would agree, I am sure, with Ms. Norton, 
if you are going to do the faith-based, you also have to make 
sure you have the professional piece in there. As the son of 
two preachers, I have all faith but I also know you need to 
have some professionalism in there too.
    Ms. Heaps. Yes.
    Mr. Cummings. One of the things I know, I know about people 
who have been addicted. They are first of all, usually some of 
the best manipulators. I couldn't help but think about a good 
friend of mine who borrowed my lawnmower, said he was going to 
cut some grass and wanted to make a few dollars and I never got 
my lawnmower back but I did see it at a used lawnmower place 
about 3 weeks later, on sale for about one-tenth of what I paid 
for it.
    I guess what I am trying to get to, I just think for people 
who may be naive with regard to recovery and there is another 
piece. One of the things I have noticed is that people will 
come to my office and say to me because they have been through 
a 12-step program and may have 6 or 7 years being clean, and 
will say, I want to start a program as if they now have become 
the experts because they have sat in the 12-step meetings, gone 
through the anniversaries with different people and for a lot 
of folks, it is a way to get into business.
    They may have good intentions, but again, they may not have 
the support systems and all that. On the other hand, one of the 
things I have noticed is a lot of people who have come before 
us in this committee have had histories of drug addiction 
problems and have clearly made some tremendous strides and are 
being very effective, or at least appear to be very effective 
and efficient in what they are doing.
    How do you make sure you guard against all of that? That is 
tough.
    Ms. Heaps. I know the depth of concern here. I can hear it 
obviously and it is not the first time I have heard it. I don't 
mean to minimize it but it really isn't rocket science. It is 
called partnership. In Chicago, our licensed, certified 
treatment counselors at TASC go and work with the faith-based 
organizations or other organizations, go into their facilities, 
talk with them, orient them, try and orientate them, try and 
work with them, look at what resources they have to offer, 
construct a program that would make sense for the clients we 
see in a community that need to be reintegrated fully. So it is 
possible to do in partnership.
    I agree with you, there has to be people who know the 
business of treating drug offenders or drug addicted 
individuals as a part of the process. What we have learned is 
when we just use that in terms of addiction and didn't deal 
with the other issues, people were falling away. They had 
finished the drug treatment and then they would reoffend and 
get back on their addiction patterns because we weren't using 
the other supports in the community, weren't dealing with the 
spiritual aspects, the job aspects and this program does in a 
unique way allow us to very effectively integrate both in an 
efficient manner.
    Mr. Cummings. Last but not least, Mr. Chairman, as you were 
talking, I could not help but think you know I am always 
fascinated by Starbucks and how Starbucks has become so 
popular. I think one of the reasons why Starbucks has become so 
popular is people need a social place to go. If they don't want 
to go to a bar, they need some place to go. I think you are 
right with regard to faith-based organizations. I think it is a 
great place for people to go. They go to church, they have all 
kinds of functions, dances, singles ministry and all this kind 
of thing, but I just want to make sure that we are very, very 
careful.
    You may be listening to me and may be saying he is 
concerned about the money but I am concerned about something 
even more important than the money, the credibility of 
treatment because up here if people don't feel that treatment 
is working, then the money is not going to come from the 
Federal Government. That is the problem. When people believe 
that it is working and we have made some tremendous strides 
thanks to the chairman and many others, toward treatment. The 
more we know there is some accountability, the more we know it 
is working, I think the more Members of Congress are open to 
seeing those funds are flowing into those programs. It is just 
a win-win when we do have that accountability.
    Dr. Passi. If I might weigh in on that for just a second, 
Congressman. The first question you ask your oncologist if you 
have cancer is not are you a recovered cancer patient, you ask 
what is your training as an oncologist. If the oncologist 
happens to have recovered from cancer, that may make him a more 
sympathetic physician.
    I think increasingly we have to ask the same kinds of 
questions of drug treatment providers and in the city of 
Albuquerque we certainly are doing that. We are first of all 
demanding the highest standard of licensure that we can under 
State regulations. More than that, we are investing local funds 
to increase the level of skill of those practitioners in 
evidence-based treatment practices. Professor Bill Miller who 
is an outstanding substance abuse treatment researcher happens 
to be at the University of New Mexico and I think Bill 
estimates that something like 80 percent of the money we spend, 
not just public money but all of our money, is being spent on 
practices that we know don't work and 20 percent of our money 
is being spent on practices that we know work.
    I think that the approach that we have adopted in 
Albuquerque, and I think the approach implicit in Access to 
Recovery, is going to try to shift that balance because this is 
not just about getting people into any treatment. It is getting 
people into the right treatment and the right treatment has to 
be those modalities that we know will succeed.
    It ain't rocket science. We know a bunch of stuff that is 
out there that is working. We just have to start paying people 
for doing it.
    Mr. Cummings. I have to ask you this and then I am 
finished.
    You said something that just hit me, just struck me. When 
we are talking about quality, do we have anything anywhere to 
your knowledge, like lawyers and teachers, you have to go back 
for certification if there is a new method. You need to know 
what is up to date. Do we have anything like that in 
Albuquerque, for example, so you keep the people who are doing 
the treatment right on the cutting edge of what it is that 
works and are constantly showing them these examples like you 
have a place right up the street which is extremely effective 
because they use this method and we believe this is the best 
practice? Are there actually mechanisms to do that?
    When you say 80 percent of the money is being spent on 
things that don't work, if that program was being funded by the 
Federal Government, it would have some real problems, I am just 
telling you.
    Dr. Passi. I think there is a real slow knowledge transfer 
process that takes place and almost every State as a mechanism 
for doing training with its providers. We in Albuquerque 
believe that can happen more quickly, especially when we keep 
in mind that it is largely money provided by the Congress and 
by the taxpayers that is funding research that tells us what 
are the best ways to approach these.
    Mr. Cummings. The key is getting that research to the 
people who are doing the treatment.
    Dr. Passi. I agree.
    Mr. Cummings. Do you all have any recommendations on that?
    Ms. Heaps. There are two national bodies that I am aware of 
but forgive me, my brain being dead, I don't remember exactly 
the names but there are counselor certification boards that 
work with individual States to develop. Illinois, for instance, 
has a State certification board that requires counselors to get 
annual training, there are standards, there is a course of 
activity based on the research coming out of NIDA. I will be 
happy to get you that information so that you have some comfort 
level that there is certainly going on a new professionalism in 
this counseling arena.
    Dr. Passi. And I think CSAT has immense resources and 
knowledge on this that you can tap to find ways to bring best 
practices to providers in the field.
    Mr. Souder. I want to ask a few more technical questions 
but I want to weigh in with a slightly different approach 
leading to a question. Both of you alluded to this and that is 
we in this country have to be careful we don't get so 
credential obsessed that we forget the point here is outcome. 
When I was a senior in high school, I took a program called 
exploratory teaching where we could go teach a class and 
because I had a lot of stuff going on, I couldn't get over to 
the elementary building and they put me in an eighth grade 
history class. It was clear that I loved history and all of a 
sudden the teacher disappeared and I had this class for the 
whole semester and I was just a senior in high school.
    An amazing thing happened. Because I loved history, four of 
the kids who were getting an F turned to A students and the 
teacher suspected that they were cheating and she retested them 
and that they turned around. I didn't have any experience in 
teaching. What I did was I loved the subject. The question is, 
are we going to measure the outcomes or are we going to be 
obsessed in the credentialing?
    If the credentialing is correct, presumably they will get 
better outcomes and much of this is medical in drug and alcohol 
treatment and therefore, it would be logical that the outcomes 
would reflect the training. But in this country to some degree, 
credentialing and I am going to make a statement that seems 
kind of role reversal but some of it is who you know and 
whether you have enough income to get the credential.
    Some of our problem in some of our urban areas is 
minorities get excluded, lower income people get excluded and 
people who can often relate to the people are in the problem. I 
know there can be a street hustle part of this but you also 
have to be careful you don't get an elitism in the credentialed 
profession that is a disconnect with the actual problems the 
individuals are facing at the street and community level.
    That leads to this question. How do you feel, because 
Director Walters has been here a number of times and we talked 
about this and some of the programs, that some of the funds 
wouldn't be delivered to the group that is providing the 
services until there is some feedback on the outcome, say they 
get 75 percent of the funds and there is a 3 or 6 month delay?
    Dr. Passi. Congressman, we are currently exploring ways in 
which to incentivize both outcomes and training. As to the 
question of credentialing, I think there has to be some base 
level of credentialing. There just are some things people have 
to know but it is less an issue of the credential of the 
practitioner than of the practice that they utilize, the 
overall approach to treatment. I think if we simply emphasize 
the credential, then we get the easy part rather than ensuring 
that what is happening in those clinicians' facilities reflects 
the cutting edge of treatment, what we in fact know works. If 
it does work, rewarding the outcomes is going to be in the long 
run the best incentive for getting people to find out how to do 
those things.
    Mr. Souder. How did you feel about delaying some of the 
benefits, the funds?
    Dr. Passi. I think some form of incentivizing payments to 
practitioners based on outcomes is a direction in which we 
certainly want to proceed.
    Mr. Souder. It really makes you focus on whether the 
outcomes are justified and balanced outcomes and will lead to 
tremendous manipulation of those outcomes. When I was in the 
graduate business program at Notre Dame and when you did case 
studies, I was the one who did the measurements because once I 
defined the measurements, then you start to define the problem, 
how you are going to address the problem and if those 
measurements have real dollar consequences, then indeed we will 
follow the outcomes. Otherwise, we will tend to stay at the 
process level.
    Ms. Heaps. I am very bad at analogies but for some reason 
this came into my head about that suggestion. It is as if we 
are building a plane and we decide we are only going to give 
you 70 percent of the cost to build the plane which may mean 
you don't get wings but the outcome will be can it fly. There 
is a caution here which is to say this is such a new endeavor 
that the need to build the system to not only treat the client 
and give the client choice, get the resources and the network 
there, develop the voucher system and move to assessing 
outcomes is such that you need to fund it, you need to get the 
plane built to see if it flies.
    Having seen it and tested it and seeing it fly, the 
question is, how long a duration and how efficient. Now you can 
begin to look at perhaps funding in terms of providers and 
vouchers, individual providers who may not have outcomes as 
good for reasons having to do with quality of service, failure 
to integrate with others. There are standards you could set up 
but I think one has to be very cautious when one is building a 
new plane and a new system to make sure that you have 
everything you need and then begin to look at how we can 
incentivize.
    Mr. Souder. We will exclude all small providers and there 
will only be big ones and the cash-flow.
    Ms. Heaps. Exactly.
    Mr. Souder. At the same time, I believe that some 
incentives are appropriate and obviously not without the wings. 
In military contracting and so on because of the overruns we 
have seen and because of obsession with the lobbying and the 
contractors as opposed to making sure the weapons system can 
actually fire, that we have had to put outcome based things in.
    I wanted to ask a couple technical questions to Dr. Passi 
since you have actually had a program. What percentage of your 
existing program was administrative versus actually cost of 
treatment? Do you know roughly?
    Dr. Passi. Our administrative costs are very low. I don't 
know that I can give you a figure.
    Mr. Souder. Under 10 percent?
    Dr. Passi. I think it is under 10 percent. There is a 
fairly large cost in the assessment and in the system. Do you 
count the assessment itself as administrative? We don't, it is 
a clinical service and probably could be billed separately.
    Mr. Souder. Is that 5 or 10 percent or is that higher?
    Dr. Passi. The assessment cost probably is running 
somewhere around $500 per assessment and I think that is about 
standard for clinicians everywhere. Our system is in fact 
administered by four people and it is about $4.5 million in 
treatment services.
    Mr. Souder. You are saying each of you gets $1 million?
    Dr. Passi. We each get $1 million. In terms of the actual 
administrators of the program, we pay four people to do it and 
that might be probably $250,000.
    Mr. Souder. Plus overhead of the office.
    When you give out the vouchers, how many of those who you 
give these vouchers to don't redeem them?
    Dr. Passi. In fiscal year 2003, we actually gave out 2,870 
vouchers. Of those, 2,631 were actually activated.
    Mr. Souder. So less than 10 percent?
    Dr. Passi. So we lost a couple hundred.
    Mr. Souder. Do you have a utilization review process to 
monitor whether they are actually spending the dollars in the 
vouchers? How do you determine the dollar of the voucher?
    Dr. Passi. The dollar amount of the voucher is based on the 
outcomes of the assessment. The assessment will say this person 
needs so much of this level of care.
    Mr. Souder. And the voucher is then estimated for the full 
cost of that program?
    Dr. Passi. The voucher is then estimated for the full cost 
of that program. The patient is then given referrals to a 
practitioner who can provide those services. The voucher is 
activated when the patient engages in service. The provider 
bills then on a fee for service basis for services that are 
authorized under the voucher. One hour of counseling, actually 
counseling is in 15 minute units, but 1 hour of counseling will 
generate a unit of service payment that will then be deducted 
from the total amount of the voucher until the voucher is 
exhausted. It could be multiple units of different kinds of 
service. A heroin addict on methadone might get x units of 
service for counseling, x units of services for the actual 
dosing.
    Mr. Souder. Does the dollar amount that you give them for 
the services calculate in whether they are eligible for 
Medicaid, have any insurance of their own and assure that the 
treatment provider doesn't in effect double bill?
    Dr. Passi. Generally we attempt to take care of that with 
the screening and assessment. Our assessment process doesn't 
say come in, get assessed and get a voucher. It says, come in 
and get assessed. So in that same fiscal year where we 
administered 2,800 vouchers, we actually did 3,300 assessments 
and about 200 of those assessments were for people who got 
referrals without a voucher. That is, they had some form of 
third party coverage or could afford to pay for the cost of 
their care individually.
    The bulk of our patients are single, young males who in New 
Mexico are not eligible for Medicaid and therefore, billing to 
Medicaid is almost not an issue in our system, but several 
hundred patients a year probably do have some form of third 
party coverage through their employer that we then refer them 
to somebody who accepts that kind of insurance.
    Mr. Souder. And you are balancing that so that there isn't, 
in effect, double billing?
    Dr. Passi. That person would not get a voucher until that 
third party coverage has exhausted.
    Mr. Souder. The same on mental health coverage, is a 
voucher eligible for mental health coverage?
    Dr. Passi. No. At this point, this is for substance abuse 
treatment services only. If the assessment indicates a co-
occurring disorder, the patient is referred to a local mental 
health provider to have those problems assessed and then a 
determination made about how that treatment will be financed.
    Mr. Souder. Ms. Heaps, in Chicago, you are dealing with 
just adults on probation, so any nuisances different?
    Ms. Heaps. Slightly. Because the State of Illinois retains 
the dollars and the voucher payment, it will double check 
against Medicaid rolls and treatment provider rolls to see if 
indeed an individual has Medicaid as an insurer, so there won't 
be double payment. I think that is a pretty important thing 
that States have to guarantee against.
    I am sorry I blanked on the last piece you talked about.
    Mr. Souder. Mental health.
    Ms. Heaps. Yes, thank you. Many of our clients of course 
have co-morbid situations and we believe mental health has to 
be a part of the recovery process, so we will be using our 
voucher system where a treatment provider cannot provide both 
substance abuse and mental health to access mental health 
services as well.
    Mr. Souder. I thank you for your efforts. I sure hope we 
can get the Portman bill moved through. At the very least, we 
have a marker out this time because long term, if we are going 
to hold people accountable and put them in prison, which is our 
highest risk population, we have to figure out as they are 
coming out that they don't come out more hardened criminals 
than they started and figure out how to deal with this. A lot 
of this as you pointed out and we hear hearing after hearing is 
drug and alcohol at least aggravated if not caused.
    I appreciate your work in that field and will be very 
interested to see the probation results in Chicago, although 
our numbers will be small compared to the overall part of your 
problem. It is so frustrating as you see the juvenile probation 
officers with 260 people and can't possibly know their names 
let alone track them all. It is an overwhelming problem and I 
appreciate New Mexico's pioneering of this. We will continue to 
watch yours because you will be basically a step ahead of the 
rest of the country as we watch for the numbers.
    Thank you very much for coming.
    With that, the subcommittee hearing stands adjourned.
    [Whereupon, at 4:15 p.m., the subcommittee was adjourned.]
    [The prepared statement of Hon. Elijah E. Cummings 
follows:]

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