[Senate Hearing 108-296]
[From the U.S. Government Publishing Office]
S. Hrg. 108-296
REAUTHORIZATION OF THE SUBSTANCE ABUSE AND MENTAL HEALTH SERVICES
ADMINISTRATION
=======================================================================
HEARING
BEFORE THE
SUBCOMMITTEE ON SUBSTANCE ABUSE AND MENTAL HEALTH SERVICES
OF THE
COMMITTEE ON HEALTH, EDUCATION,
LABOR, AND PENSIONS
UNITED STATES SENATE
ONE HUNDRED EIGHTH CONGRESS
FIRST SESSION
ON
EXAMINING PROPOSED LEGISLATION AUTHORIZING FUNDS FOR THE SUBSTANCE
ABUSE AND MENTAL HEALTH SERVICES ADMINISTRATION, FOCUSING ON THE
IMPORTANCE OF SUBSTANCE ABUSE PREVENTION
__________
JULY 15, 2003
__________
Printed for the use of the Committee on Health, Education, Labor, and
Pensions
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COMMITTEE ON HEALTH, EDUCATION, LABOR, AND PENSIONS
JUDD GREGG, New Hampshire, Chairman
BILL FRIST, Tennessee EDWARD M. KENNEDY, Massachusetts
MICHAEL B. ENZI, Wyoming CHRISTOPHER J. DODD, Connecticut
LAMAR ALEXANDER, Tennessee TOM HARKIN, Iowa
CHRISTOPHER S. BOND, Missouri BARBARA A. MIKULSKI, Maryland
MIKE DeWINE, Ohio JAMES M. JEFFORDS (I), Vermont
PAT ROBERTS, Kansas JEFF BINGAMAN, New Mexico
JEFF SESSIONS, Alabama PATTY MURRAY, Washington
JOHN ENSIGN, Nevada JACK REED, Rhode Island
LINDSEY O. GRAHAM, South Carolina JOHN EDWARDS, North Carolina
JOHN W. WARNER, Virginia HILLARY RODHAM CLINTON, New York
Sharon R. Soderstrom, Staff Director
J. Michael Myers, Minority Staff Director and Chief Counsel
______
Subcommittee on Substance Abuse and Mental Health Services
MIKE DeWINE, Ohio, Chairman
MICHAEL B. ENZI, Wyoming EDWARD M. KENNEDY, Massachusetts
JEFF SESSIONS, Alabama JEFF BINGAMAN, New Mexico
JOHN ENSIGN, Nevada JACK REED, Rhode Island
Karla Carpenter, Staff Director
David Nexon, Minority Staff Director
(ii)
C O N T E N T S
__________
STATEMENTS
TUESDAY, JULY 15, 2003
Page
DeWine, Hon. Mike, a U.S. Senator from the State of Ohio, opening
statement...................................................... 1
Reed, Hon. Jack, a U.S. Senator from the State of Rhode Island,
opening statement.............................................. 2
Frist, Hon. Bill, a U.S. Senator from the State of Tennessee,
prepared statement............................................. 3
Kennedy, Hon. Edward, a U.S. Senator from the State of
Massachusetts, prepared statement.............................. 4
Curie, Charles G., Administrator, Substance Abuse and Mental
Health Services Administration, U.S. Department of Health and
Human Services................................................. 5
Prepared statement........................................... 8
Murray, Hon. Patty, a U.S. Senator from the State of Washington,
prepared statement............................................. 21
Taft, Hope, First Lady of Ohio; Lewis E. Gallant, Executive
Director, National Association of State Alcohol and Drug Abuse
Directors, Incorporated; Martha B. Knisley, Director,
Department of Mental Health, District of Columbia, on Behalf of
the National Association of State Mental Health Program
Directors and the Campaign for Mental Health Reform; and Gloria
Walker, Member, Board of Directors, National Alliance for the
Mentally Ill................................................... 24
Prepared statements of:
Mrs. Taft................................................ 27
Mr. Gallant.............................................. 31
Ms. Knisley.............................................. 38
Ms. Walker............................................... 43
ADDITIONAL MATERIAL
Statements, articles, publications, letters, etc.:
Questions of Senator Murray for Panel I and Panel II......... 22
Michael Faenza, National Mental Health Association........... 55
Ohio Student Survey 2002..................................... 58
(iii)
REAUTHORIZATION OF THE SUBSTANCE ABUSE AND MENTAL HEALTH SERVICES
ADMINISTRATION
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TUESDAY, JULY 15, 2003
U.S. Senate,
Subcommittee on Substance Abuse and Mental Health Services,
of the Committee on Health, Education, Labor, and Pensions,
Washington, DC.
The subcommittee met, pursuant to notice, at 10:08 a.m., in
room SD-430, Dirksen Senate Office Building, Hon. Mike DeWine
(chairman of the subcommittee) presiding.
Present: Senators DeWine, Reed, and Murray.
Opening Statement of Senator DeWine
Senator DeWine. Good morning. We welcome all of you today
to the first hearing of the new Subcommittee on Substance Abuse
and Mental Health Services. I am honored to be the chairman of
this subcommittee. I think this is an important subcommittee.
I look forward to working with my friend and colleague from
Massachusetts, Senator Kennedy, on these very, very important
issues. Senator Kennedy, of course--I do not have to tell
anyone in this room--is truly a leader in this area and has
many wonderful insights into these issues.
While the subcommittee's primary responsibility will be the
reauthorization of SAMHSA, I intend for this to be an active
subcommittee, and I look forward to holding additional hearings
on other issues that are related to substance abuse and to
mental health.
I would just say to our audience and to others that we are
very open to ideas as far as what hearings we should be
holding, and I know my staff cringes when I say that, but this
is an energetic group up here, and we are looking forward to
having many hearings. This is obviously a wide open field, and
a very important field.
As some of you may know, these issues are not new to me. I
have been long involved both in this body and my home State of
Ohio in efforts aimed to help prevent substance abuse and also
in treating mental illness. I authored two significant pieces
of legislation in this area in Congress--the reauthorization of
the Safe and Drug-Free Schools Act and the Mental Health Courts
bill.
During this session of Congress, I have introduced the
Mentally Ill Offender Treatment and Crime Reduction Act as well
as the Communities Combating College Drinking and Drug Use Act.
In addition to these bills, I look forward to working on
the reauthorization of SAMHSA with the other members of this
committee and of course with Senator Kennedy.
The Substance Abuse and Mental Health Services
Administration serves a vital role in this country's public
health system. Established in 1992, SAMHSA is the primary
Government agency responsible for substance abuse and mental
health prevention and treatment services.
At today's hearing and at future hearings, I look forward
to hearing from the experts as to how the programs are working,
if there are any problems, and what recommendations they may
have for reauthorization. I am pleased to move ahead on these
issues and to be working with all the committee members in this
endeavor, and I thank all of you for being here.
Senator Reed?
Opening Statement of Senator Reed
Senator Reed. Thank you very much, Mr. Chairman.
First, let me congratulate you for being not only
instrumental in organizing this new subcommittee but for all of
your work on these issues. I know how passionately and how
effectively you advocate for so many things but particularly
those issues under the jurisdiction of this subcommittee.
Let me also welcome Mr. Curie and commend him for his
wisdom, foresight, and brilliance in recommending and
appointing Kathryn Power as the new director of the Center for
Mental Health Services, a truly remarkable recognition that in
Rhode Island, we have the very best director of the Department
of Mental Health, Retardation, and Hospitals in the country.
Kathryn is someone whom I have had the pleasure of working with
for more than a decade. She has served administrations of both
parties. She has done it with great professionalism. She has
really led the way in integrating mental health and substance
abuse services for people with co-occurring disorders, and she
is going to be a great leader at the Center for Mental Health
Services. And then, when she puts on her Navy uniform and
orders you around, Mr. Curie, you will appreciate the full
power that she commands.
[Laughter.]
I was pleased to be part of the last SAMHSA reauthorization
in 1999, and these are incredibly important issues, and I look
forward as the chairman does to your advice as we go forward.
One of the critical issues is really capacity. At the State
level, we see a huge surge of people with real problems and
real needs, and we do not have the resources, either
institutionally or in the neighborhood settings, to deal
effectively. And we all recognize and say repeatedly that early
intervention, be it a mental health issue or a substance abuse
issue, and rapid response is the only way to do it, the most
cost-effective way to do it, and yet we still find ourselves
telling people to wait, with people juggling different
locations and times to get into treatment. That is something
that I think we have to deal with seriously.
Again, I look forward to the hearing, and I am just so
pleased that Chairman DeWine has called it and will be leading
this subcommittee.
Thank you.
Senator DeWine. Senator Reed, thank you very much.
At this time I submit for the record the prepared
statements of Senator Frist and Senator Kennedy.
[The prepared statement of Senator Frist follows:]
Prepared Statement of Senator Frist
I would like to recognize Chairman DeWine for calling
today's important hearing to examine issues related to mental
health and substance abuse. I commend him for his efforts to
reauthorize the Substance Abuse Mental Health Services
Administration (SAMHSA), and look forward to working with him
in this effort.
Earlier this year, President Bush highlighted the
importance of drug addiction prevention and treatment as an
important priority for the nation. I share this belief, and
this committee has worked in a bipartisan manner on these
issues in the past.
In the 106th Congress, I had the opportunity to work with
Senator Kennedy and other members of this committee to
reauthorize SAMHSA as part of the Youth Drug and Mental Health
Services Act. The ``Youth Drug'' Act was a comprehensive
attempt to address the tragedy of drug use affecting our
children. According to the 2001 National Household Survey on
Drug Abuse, almost 5 million youths aged 12 to 17 (21 percent)
had used an illicit drug in the past year and about 10.1
million persons aged 12 to 20 used alcohol in the past month.
More than 6 million children lived with at least one parent who
abused or was dependent on alcohol or an illicit drug.
These challenges are particularly prevalent among
minorities. In 2000, Hispanic females aged 12 to 17 were at
higher risk for suicide than other youths. Only 32 percent of
Hispanic young women and girls at risk for suicide during the
past year, however, received mental health treatment during
this same time period.
There are many factors for this increase in youth substance
abuse. As a father, I am particularly concerned with a decline
in the disapproval of drug use and in the perception of the
risk of drug use among our youth.
To help address this problem, the ``Youth Drug'' bill
placed a renewed focus on youth and adolescent substance abuse
and mental health services, while providing greater flexibility
for States and new accountability in the use of funds based on
performance. Another important goal of this effort was to allow
faith-based addiction treatment and prevention programs to be
eligible for Federal funds through ``charitable-choice''
provisions. These efforts have helped SAMHSA more efficiently
carry out its goals of promoting accountability, enhancing
capacity, and assuring effectiveness of its substance abuse and
mental health treatment and prevention programs.
However, much remains to be done. There are nearly 44
million Americans affected by mental illness and nearly 17
million Americans with substance abuse and addiction problems.
Unfortunately, most of these people are not receiving the
treatment they need. In fact, last year less that one-half of
Americans suffering from mental illness and less than twenty
percent of Americans with substance abuse or addiction problems
received treatment.
But these problems are particularly acute for the seven to
ten million individuals with co-occurring disorders (who have
at least one mental disorder as well as an alcohol or drug use
disorder). These individuals experience particular difficulties
in diagnostic and treatment services, although these disorders
are often treatable when they present as individual chronic
illnesses.
These statistics underscore the importance of reauthorizing
the Substance Abuse and Mental Health Services Administration.
Today's hearing represents the beginning of that important
process. I once again commend the Chairman for calling today's
hearing and look forward to working with him, with the Members
of the Subcommittee and Committee, and with today's witnesses
in this important endeavor.
[The prepared statement of Senator Kennedy follows:]
Prepared Statement of Senator Kennedy
I commend Senator DeWine for calling this hearing and for
his leadership in creating the Subcommittee on Substance Abuse
and Mental Health.
I'm pleased that our first hearing on the Reauthorization
of SAMHSA--the Substance Abuse and Mental Health Services
Administration--focuses on treatment and prevention services
for individuals who are mentally ill or suffering from
substance abuse.
I join in welcoming Charles Curie, the Administrator of
SAMHSA, and I commend him for his long track record of
innovation and treating individuals with addictions and mental
illness with dignity. I look forward to working closely with
him as we review the agency's mission and reauthorize its
programs.
Three years ago, Congress passed the Youth Drug and Mental
Health Services Act, which reauthorized SAMHSA. The bill was
developed with Senator Frist in the aftermath of the Columbine
tragedy and directly addressed the problem of violence in
children's lives. It created community partnerships in law
enforcement, educational support, and mental health and
substance abuse programs to provide a comprehensive response to
violence. National and regional centers of excellence were
established to deal with the psychological problems resulting
from suffering or witnessing a traumatic event, such as
community violence or school violence. These supports became
even more important as the nation struggled with the aftermath
of September 11th.
Other initiatives have been less successful. With Senator
Domenici, we added programs to address the needs of adults and
children who were suffering from a lack of access to needed
treatment, such as a program to establish response teams and
designate centers to provide emergency mental health treatment
for patients. Unfortunately, these programs have not received
the resources needed to get them off the ground. A program to
coordinate child welfare services and mental health services
has not been funded. We know that budgets are tight, but I hope
we can work together to redirect resources to these important
programs.
We're so proud of SAMHSA's work in reducing discrimination
against the mentally ill and those who suffer from addiction.
Through research and treatment, we have been able to give them
dignity and help them to improve their lives.
Another issue that divides us is the question of whether
religious organizations receiving Federal funds can engage in
job discrimination. I strongly support the mission of faith-
based organizations and their exemplary role in providing
services to people in need. But I have worked for many years to
end discrimination and promote the separation of church and
State, and I oppose the use of Federal funds for job
discrimination and proselytizing for religions.
In October we will celebrate the fortieth anniversary of
the day the Mental Retardation Facilities and Community Mental
Health Centers Construction Act was signed into law by
President Kennedy. That legislation brought dignity to the
mentally ill by assisting them and enabling them to move out of
mental institutions and into their communities. The need today
is to strengthen the resources of our communities so that
persons living with mental illness can be successful,
contributing members of society.
I look forward to working with my colleague to reauthorize
SAMHSA in ways that make it stronger and more supportive of
these important community investments in children and adults
with mental illness.
Senator DeWine. Charles Curie joins us today as the
administrator of SAMHSA. He has over 25 years of professional
experience in the mental health and substance abuse field.
Prior to his confirmation as the administrator in October of
2001, he was deputy secretary for mental health and substance
abuse services for the Department of Public Welfare in
Pennsylvania. Before his service in the Ridge administration,
he served as president and CEO of the Helen Stevens Community
Mental Health Center in Carlisle Pennsylvania and executive
director and CEO of the Sandusky Valley Center in Tiffin, OH.
He is a native of Indiana, holding an undergraduate degree from
Huntington College, a master's degree from the University of
Chicago School of Social Service Administration and is
certified by the Academy of Certified Social Workers.
We thank you very much for being with us, and we look
forward to your testimony, Mr. Curie. You may proceed.
STATEMENT OF CHARLES G. CURIE, ADMINISTRATOR, SUBSTANCE ABUSE
AND MENTAL HEALTH SERVICES ADMINISTRATION, U.S. DEPARTMENT OF
HEALTH AND HUMAN SERVICES
Mr. Curie. Thank you, Mr. Chairman, and thank you Senator
Reed. It is a privilege to be sharing with you this morning. I
want to thank you for the opportunity to present and your
invitation to consider the reauthorization of the Substance
Abuse and Mental Health Services Administration.
At this time, I would also like to request that my written
testimony be submitted for the record.
At the outset, first of all, I did spend 10 years as a
Buckeye in Ohio.
Senator DeWine. I noted that; thank you.
Mr. Curie. I was a native Hoosier. I always say I grew up
professionally in Ohio and grew old in Pennsylvania, and now we
will see what happens in the current position.
Senator Reed. You could retire to Rhode Island.
Mr. Curie. Yes--that could be a good plan.
At the outset, I would like to introduce you to three
members of SAMHSA's executive leadership team who are with me
today. First is Dr. H. Wesley Clark, the director of SAMHSA's
Center for Substance Abuse Treatment; also, Ms. Beverly Watts
Davis, the director of SAMHSA's Center for Substance Abuse
Treatment; and finally, Mr. James Stone, who is SAMHSA's deputy
administrator just coming to us in his second week, having been
commissioner of mental health in New York until about 2 weeks
ago. Ms. Gail Hutchings, who is acting director of SAMHSA's
Center for Mental Health Services, is unable to be here today,
but she is probably only second to me in terms of being
thrilled that Kathryn Power did say yes to becoming director
for the Center for Mental Health Services, and I would support
everything you said, Senator, about Ms. Power.
I would also like to take a moment to thank the leaders in
the substance abuse and mental health services field who are in
attendance today and will testify before the subcommittee.
Let me begin with a story the President used when he
launched the New Freedom Commission on Mental Health. It
illustrates what happens to people all too often in the mental
health or substance abuse systems if they get into one of the
service systems at all.
A 14-year-old boy started experimenting with drugs to ease
his severe depression. This former honor student became a drug
addict, dropped out of school, was incarcerated six times in 16
years. Only when he was 30 years old did the doctors finally
diagnose his condition as bipolar disorder, and he began a
successful long-term treatment program which helped him attain
and sustain recovery.
I tell you this story because this tragedy is preventable.
This young man needlessly lost 16 years of his life, which at
the same time cost the taxpayers countless dollars.
I tell you this story because today, effective prevention,
early intervention and treatment for mental and substance abuse
disorders are available, and recovery is possible. For example,
after a review of almost 800 programs, we identified 50 model
substance abuse prevention programs. On the average, these
model programs produced a 25 percent reduction in substance use
by program participants. We are working to ensure that
effective prevention programs are used in communities
nationwide through the development of a strategic prevention
framework.
We have shown that substance abuse treatment can yield a 50
percent reduction in drug use 1 year after treatment,
accompanied by improved job prospects, increased incomes, and
better physical and mental health. After treatment, clients are
less likely to be homeless or to be involved in criminal
activity or risky sexual behaviors.
Our President clearly understands that treatment works and
recovery is real. As you know, in his State of the Union
Address, he proposed a new substance abuse treatment initiative
called Access to Recovery. This new initiative will provide
people seeking drug and alcohol treatment vouchers to pay for a
range of appropriate community-based services. As the President
said in his speech, our Nation is blessed with recovery
programs that do amazing work. Now we must connect people in
need with people who provide the services.
We face the same challenge in our mental health programs as
SAMHSA. Our Children's Mental Health Program has produced
results, including increased functional ability, increasing
school attendance and grades, and reducing contacts with the
juvenile justice system. And we are embarking on a national
project to promote the widespread adoption of six evidence-
based practices, treatments that have consistently been proven
to generate positive outcomes for adults with serious mental
illness.
It is clear that investments in substance abuse and mental
illness prevention, early intervention and treatment pay off in
big ways--that is, if we can get the services to those who need
them.
Much work lies ahead as we continue to bring scientific
discoveries to community-based services. To guide our work at
SAMHSA, we have reinforced our statutory mission to focus on
services. Instead of the old philosophy of ``Let a thousand
flowers bloom,'' we are now nurturing a few sturdy redwoods. We
have renewed and more sharply focused SAMHSA's mission and
vision, aligning them with both HHS goals and the White House.
In keeping with the President's New Freedom Initiative,
SAMHSA's vision is to promote a life in the community for
everyone. When someone says ``You need to get a life,'' you
know what that means; that is what we need to be about with the
people we serve. We are working to achieve that vision through
our mission, which is building resilience and facilitating
recovery.
To accomplish our mission, we have aligned our resources,
staff, and dollars with core priority areas identified in our
matrix of program priorities and cross-cutting principles. We
have also taken steps to expand our partnership with NIH to
produce a comprehensive science-to-services agenda that can
help reduce the time between discovery of an effective
treatment or intervention and its adoption in community-based
care.
Today, the Institute of Medicine tells us it can take up to
20 years for that to happen. With the near doubling of the NIH
budget driving even more clinical research and development,
that gap may grow still greater unless a fundamental change
occurs in how scientific advances are incorporated in community
care.
I believe our program priority matrix and renewed focus on
our services mission and the development of a comprehensive
data strategy that helps us measure and manage program
performance will help us accomplish and realize our vision.
That vision is to help ensure people of all ages with or at
risk for mental and addictive disorders have the opportunity
for recovery and a fulfilling life in their community,
including a job, a home, and meaningful personal relationships.
Thank you, and I look forward to your questions.
[The prepared statement of Mr. Curie follows:]
Prepared Statement of Charles G. Curie, M.A., A.C.S.W.
Introduction
Mr. Chairman and Members of the Subcommittee, I am honored to
present to you the vision, mission, and programs of the Substance Abuse
and Mental Health Services Administration (SAMHSA or the Agency). Our
mission, as envisioned by Congress when SAMHSA was created, is to
``fully develop the Federal Government's ability to target effectively
substance abuse and mental health services to the people most in need
and to translate research in these areas more effectively and more
rapidly into the general health care system.''
Over the years, SAMHSA and its three Centers, the Center for
Substance Abuse Prevention, the Center for Substance Abuse Treatment
and the Center for Mental Health Services, have worked with State and
local governments, consumers, families, service providers, professional
organizations, our colleagues in HHS, the Office of National Drug
Control Policy, and Congress to achieve its mission.
The Agency's work has shown prevention, early intervention, and
treatment for mental and substance use disorders pay off in terms of
reduced HIV/AIDS, crime, violence, suicide, homelessness, injuries, and
health care costs, and increased productivity, employment, and
community participation. Data confirms that the human and economic cost
is much lower when we prevent or intervene early with the best
research-based tools available.
During my first year at SAMHSA, I led the Agency through a critical
self-assessment of how it has met its statutory mandate during its
first 10 years. Based on that assessment, we identified efficiencies,
ways to strengthen our overall effectiveness, increase our capacity,
and enhance our accountability both to you and to the populations this
Agency has a responsibility to serve.
I also found that like many organizations, as SAMHSA continued to
grow, ``mission creep'' had set in. The Agency's initial focus on
increasing access to services and using research findings to improve
the quality of services available had lost clarity. Increasingly, staff
and resources were devoted to the important work of services research
what SAMHSA called ``knowledge development.'' And, the operating
principle had become let a thousand flowers bloom.
Today, consistent with Health and Human Services (HHS) Secretary
Tommy G. Thompson's leadership and vision, we are nurturing a few
sturdy redwoods. We have renewed and more sharply focused SAMHSA's
mission and vision, aligning them both with HHS goals and President
Bush's New Freedom Initiative and management agenda. In keeping with
the New Freedom Initiative, SAMHSA's vision is ``a life in the
community for everyone.''
Working together with the States, national and local community-
based and faith-based organizations, and public and private sector
providers, we are working to ensure that people with or at risk for a
mental or addictive disorder have an opportunity for a fulfilling life,
a life that is rich and rewarding, that includes a job, a home, and
meaningful relationships with family and friends.
We have defined a ``rewarding life'' not by what it might mean to
the people who work at SAMHSA, but through talking to people in
recovery. People in recovery do not say that they need a primary care
physician or a caseworker to follow them around. They do not say they
need a psychiatrist, an addictions counselor, or even a social worker.
They say they need a job, a home, and meaningful personal
relationships. They want a life, a real life with all of its rewards.
We are working to achieve that vision through a mission that
fulfills our mandate from Congress and focuses our attention on the
outcomes we are seeking: to build resilience and facilitate recovery
for people with or at risk for substance abuse and mental illness.
To ensure that all SAMHSA programs are science-based, results-
oriented, and aligned with the Agency's vision and mission, I initiated
a strategic planning process that guides our decision making in
planning, policy, communications, budget, and programs. The process is
designed around three core objectives--Accountability, Capacity, and
Effectiveness or, in short, ACE!
To guide our work and to keep our vision and mission real, we have
created a Matrix of agency priorities and principles to guide program
development and resource allocation. We have provided you with a copy
of the Matrix. The Matrix is a visual depiction of our priorities and
principles, among them: co-occurring mental and substance abuse
disorders, seclusion and restraint, substance abuse treatment capacity,
prevention and early intervention, transforming mental health care,
criminal justice, children and families, aging, homelessness, disaster
response, and HIV/AIDS. The Matrix was created to be a flexible
management tool and it will adjust with the needs of the field and of
the people we serve as time passes and new trends emerge.
With a fiscal year 2003 budget of just under $3.2 billion, SAMHSA's
program dollars support formula grant programs, primarily the Substance
Abuse Prevention and Treatment Block Grant and the Community Mental
Health Services Block Grant, a portfolio of discretionary grants, and
three major national surveys on substance use. In the interest of time,
rather than discuss each of our program areas, I want to focus on three
most central to our mission and vision.
BUILDING SUBSTANCE ABUSE TREATMENT CAPACITY
The Substance Abuse Prevention and Treatment Block Grant, with its
required maintenance of effort, supports and maintains the basic
treatment infrastructure that exists in the Nation. Targeted Capacity
Expansion (TCE) grants address new and emerging substance abuse trends.
By focusing on local needs, these grants provide the flexibility and
agility to meet treatment and treatment system needs in the most
relevant way. In the current fiscal year, we have developed a new State
TCE program that includes a focus on screening and both early and brief
interventions. This focus will help expand the continuum of care
available in States.
Together, both the Block Grant and TCE programs have made strides
in expanding our capacity for substance abuse treatment. They are
necessary; they are effective; but alone, they have not yet proven to
be sufficient. Our National Household Survey on Drug Abuse found that
in 2001, 5 million of the 6.1 million people needing treatment for an
illicit drug problem never got help. Of the 5 million, only 377,000
reported that they felt they needed treatment for their drug problem.
In fact, 101,000 people who knew that they needed treatment sought help
but were unable to find care.
President Bush emphasized this very point in his January 2003 State
of the Union Address when he said, ``Too many Americans in search of
treatment cannot get it.'' He reaffirmed his commitment to expand the
Nation's substance abuse treatment capacity by proposing Access to
Recovery, a $600-million program to help an additional 300,000
Americans receive treatment over the next 3 years. The first $200
million installment is included in the President's proposed fiscal year
2004 budget for SAMHSA under current legislative authorities.
The President's substance abuse treatment initiative, Access to
Recovery, will use vouchers to purchase substance abuse treatment and
support services. It enables us to achieve key objectives identified by
substance abuse treatment administrators and providers, legislators and
policy makers, and people in recovery and their families as critical to
moving the substance abuse treatment field forward.
First, it acknowledges that there are many pathways to recovery.
Using vouchers, individuals, for the first time, will be empowered to
choose the provider who best meets their needs, whether the setting is
nonprofit, proprietary, community-based, or faith-based. The voucher
mechanism allows recovery to be pursued in an individualized way,
providing consumer choice, the epitome of accountability.
Second, it will reward performance by offering financial incentives
for providers who produce results. Outcomes that demonstrate patient
success--measures of recovery--such as cessation of drug or alcohol
use, no involvement with the criminal justice system, securing
employment, social supports, living situations, access to care, and
retention in care will determine reimbursement.
Third, it will increase treatment capacity by expanding access to
treatment and the array of support services that are critical to
recovery. The initial $200 million investment is expected to result in
treatment availability for an additional 100,000 people per year.
This initiative, coupled with SAMHSA's ongoing programs to build
treatment capacity, can help create profound change in the delivery and
accountability of substance abuse treatment services that can help make
a difference in the lives of millions of Americans.
The Senate fiscal year 2004 Labor, Health and Human Services, and
Education Appropriations Committee bill provides no funding for this
initiative. We strongly urge the Senate to appropriate the full $200
million requested for this critical activity and would appreciate any
help you can provide.
We are confident that States are prepared to successfully implement
this program at the $200 million level. We are working aggressively to
prepare States for this initiative and work through implementation
issues related to assessments, accreditation, administrative expenses,
and other key areas.
PREVENTION/EARLY INTERVENTION
To help achieve the goal of the President's National Drug Control
Policy to reduce illegal drug use by young people and adults by 25
present each within 5 years, SAMHSA is reengineering its approach to
substance abuse prevention. Over the years, SAMHSA's work has shown
that substance abuse prevention can be incredibly effective, if it is
done right.
Prevention not only can reduce the numbers of individuals who
become dependent on substances of abuse, but also it can deter
substance abuse in the first place. It can pay off not only in terms of
health care costs, but also in terms of crime and violence,
homelessness, and joblessness. It also can help us enhance treatment
capacity by simply reducing the absolute numbers of people who are
abusing or dependent on illicit drugs.
We have growing evidence that tells us which models of prevention
work well, which promising models need further evaluation, and which
models lack any strong evidence of effectiveness. We do not need to re-
invent that knowledge. We need to apply what we know. We need to ensure
that our dollars support known effective prevention programs, programs
built on a solid evidence base of ongoing research.
To that end, over the past year, SAMHSA has been working to create
a strategic framework for prevention, built on both science-based
theory and evidence-based practices. We know from ongoing evaluation of
our programs that to succeed, prevention programs must be built at the
level of families and communities and must engage individuals,
families, and entire communities.
SAMHSA's State Incentive Grants (SIG) for Community-based Action
are a stepping-off point to achieve that end. It forms the foundation
on which our strategic prevention framework rests. The SIG program
provides funds to the Governors' offices of individual States and
territories. It also is based on those prevention practices that we
know are effective. It enables Governors to develop a coordinated
approach to prevention and to determine where and what the greatest
needs are. At least 85 percent of funds are then directed by the
Governor to community-level prevention programs.
Last year, the SIG program provided resources to over 2,700
community-based and faith-based organizations, community anti-drug
partnerships and coalitions, local governments, schools, and school
districts. It has promoted the development of thoughtfully crafted,
evidence-based State-community partnerships and strategies that enable
communities to work on their own greatest challenges in substance abuse
prevention.
Most of the community programs have adopted science-based substance
abuse prevention strategies, many of which have been evaluated and
endorsed by SAMHSA as effective models. These model programs, listed in
our National Registry of Effective Prevention Programs, yield on
average a 25 percent reduction in substance use by program
participants.
Our strategic prevention framework sets into place a step-by-step
process that empowers communities to identify risk and protective
factors for substance abuse in their communities and to implement the
best and most effective prevention efforts for their specific needs.
Critically, the framework includes feedback to ensure accountability
and effectiveness of our program efforts.
TRANSFORMING MENTAL HEALTH CARE
SAMHSA's vision and mission of a life in the community for everyone
is a direct outgrowth of the President's New Freedom Initiative. That
same vision and mission guides our efforts to help ensure that people
with mental illness have access to effective and appropriate,
community-based mental health services that can help them become or
remain engaged participants in the life of their communities.
Consistent with other areas of SAMHSA's programming,
accountability, capacity, and effectiveness are central to our mental
health services discretionary and formula grant programs and
activities. Three of those programs are the Projects for Assistance in
Transition from Homelessness, the Children's Mental Health Services
Program, and the Community Mental Health Services Block Grant.
The Projects for Assistance in Transition from Homelessness (PATH)
program continues to generate positive results by bringing an estimated
147,000 homeless people into treatment for mental disorders and
substance abuse, as well as providing referrals for housing. PATH gives
States flexibility in designing their programs, but helps ensure
efficiency by requiring States to match funds with one dollar for every
three dollars received in Federal funds. In recent years, State and
local support has been more than double the sums required by the match.
Over its history, the program has continued to exceed its targets for
reaching this often difficult to serve population.
The Children's Mental Health Services Program builds community-
based systems of care for children with serious emotional disturbances
(SED) and their families. The program supports services for almost
17,000 children and adolescents with SED and their families. It creates
a web of services, linking school, family, juvenile justice, and mental
health and other health care together to provide an integrated approach
to meeting the highly individualized needs of children with SED and
their families. Outcome data continue to show that this integration
decreases use of inpatient care, increases school attendance and
performance, and decreases contacts with the juvenile justice system.
Several States have adopted statutes mandating this kind of approach to
treatment for children with SED, but the value of a similar approach
for other populations of individuals with serious mental illnesses
cannot be discounted, either.
The Community Mental Health Services Block Grant program provides
funds to the States to provide comprehensive community mental health
services to adults with serious mental illness and children with SED.
The program's overall goal is to move care for these adults and
children from costly and restrictive inpatient hospital care to the
community. The Block Grant is funded at $437 million this fiscal year,
or about 2.5 percent of State expenditures on mental health services.
As you may know, the President's New Freedom Commission on Mental
Health has completed its work, and its final report to the President is
expected soon. Once the final report is submitted to the President, the
Administration will evaluate the report and its recommendations.
As a result, we expect there may ultimately be some far-reaching
implications for SAMHSA's mental health programs. We look forward to
working with the Congress to implement the steps needed to improve the
mental health service delivery system in America.
NATIONAL SURVEYS
Another area of SAMHSA responsibility is to inform the President,
the Congress, the substance abuse prevention and treatment and mental
health service fields, and the American public on the status of
substance use and treatment services in the Nation. One of those
measures is provided by our National Household Survey on Drug Abuse.
The National Household Survey provides national and comparable State-
level estimates of substance use, abuse, and dependence. It also
provides an ongoing source of nationally representative information on
mental health and access to mental health services. The analysis of
trends over time from the survey, alone and in combination with other
data sources, provides an invaluable tool to measure outcomes of the
National Drug Control Strategy and to report our progress to Congress.
Two other major national survey's conducted by SAMHSA include the
Drug Abuse Warning Network (DAWN) and the Drug and Alcohol Services
Information System (DASIS). The DAWN obtains information on drug-
related admissions to emergency departments and drug-related deaths
identified by medical examiners. The DASIS consists of three data sets
developed with State governments. These data collection efforts provide
national and State-level information on the substance abuse treatment
system.
IMPROVED MANAGEMENT OF SAMHSA RESOURCES
SAMHSA is working to develop an overall data strategy and to shift
the block grants to performance partnership grants. With regard to
Performance Partnership Grants, or PPGs, SAMHSA has been working on
this for sometime, and I am pleased to say our plans for transforming
the block grants will be submitted to you very soon as we prepare to
send a report to Congress, as requested, on these plans.
Currently, SAMHSA and the States have agreed on performance
measures. We have identified the core measures on which all States will
report. We are working to revise the fiscal year 2005 block grant
applications to include performance data collection. Given that the
PPGs comprise almost 80 percent of SAMHSA's budget, we are working to
align the PPG performance measures with the Access to Recovery
initiative and with potential recommendations of the President's New
Freedom Commission on Mental Health.
Through both the Access to Recovery initiative and the PPGs, we
have identified seven domains for specific data needed to capture the
concept of recovery and determine the effectiveness of our programs. As
I mentioned before, these include: drug or alcohol use, involvement
with the criminal justice system, securing employment, social supports,
living situations, access to care, and retention in care. These
domains, when finalized through the PPG performance measures and the
work we are doing on Access to Recovery, will likely become the same
ones used across all of our programs. It just makes sense to use
consistent measures across programs that have the main goal of building
resilience and facilitating recovery.
To make sure we are moving in the right direction when it comes to
collecting, analyzing, aggregating, and ultimately turning data into
action, I have set up what I call the ``Data Strategy Workgroup.'' I am
determined to build a system that uses the health information
technology we have today to help us measure and manage performance and
in the end benefit the client which is and always should be our
overriding goal.
In many ways the ``Data Strategy'' is starting from a grassroots
perspective. The workgroup contains key SAMHSA staff who will be
looking at ways to build a collection system that, while protecting
confidentiality, will be able to capture a clear picture of the
situation and the needs and treatment status of the individual. Such
information can then be gleaned to provide a picture at the local/
county level.
That information then will be translated to create a State-level
picture and combined to create a national-level picture of outcomes.
Capturing and using the best data, especially where the PPGs and
voucher program are concerned, will allow us, as never before, to
clearly recognize outcomes as part of the quality and effectiveness
equation. Using a limited number of domains will gather data on a
handful of accurate measures, rather than create a sea of minimally
useful data, thus trimming and reducing the reporting requirements of
the States.
Finally, SAMHSA is actively promoting a Science to Services agenda.
After years of discussion about SAMHSA's role in ``knowledge
development'', we are reinforcing our mission in services and in
bringing evidence-based, effective products of research to community
programs nationwide. We are also reinforcing the clear expectation
contained in our authorizing legislation that SAMHSA and the National
Institutes of Health (NIH) should collaborate to promote the study,
dissemination, and implementation of research findings that improve the
delivery and effectiveness of substance abuse and mental health
services. As a result, we have recently taken steps to expand our
partnership with the NIH to produce a comprehensive ``Science to
Services'' agenda that is responsive to the needs of the field. We have
initiated a dialogue with the Directors of NIH's National Institute on
Alcohol Abuse and Alcoholism, National Institute on Drug Abuse, and
National Institute of Mental Health, and we have made a common
commitment to this agenda. We are working to define and develop a
``Science to Services'' cycle that reduces the time between the
discovery of an effective treatment or intervention and its adoption as
part of community-based care, which the Institute of Medicine tells us
today can take up to 20 years.
CONCLUSION
Mr. Chairman and Members of the Subcommittee, as the Administrator
of SAMHSA, I have taken a hard look and taken steps to clarify SAMHSA's
vision and mission. We have set the Agency on a new course being guided
by accountability, capacity, and effectiveness. We will continue to
manage the Matrix. With the imperative of the President's commitment to
grow our substance abuse treatment capacity coupled with the findings
of the New Freedom Mental Health Commission, and with your support
SAMHSA, we will continue to work toward achieving a vision of a life in
the community for everyone.
Thank you for the opportunity to appear today. I will be pleased to
answer any questions you may have.
Senator DeWine. Senator Reed?
Senator Reed. Thank you very much, Mr. Chairman.
Thank you again, Mr. Curie, for your testimony and for your
leadership. I believe you have assembled an extremely good team
and look forward to working with you.
You mentioned the President's Access to Recovery
Initiative. Part of that is a voucher program, which there are
arguments on both sides, but one of the issues is how it
addresses the capacity problem. Giving an individual a voucher
and then having him or her look in vain for a provider is
difficult. And on the other side of the coin, unless you have a
rather predictable funding stream as a provider, you are going
to get out of the business--if it is, ``I have got to attract
people, I have got to advertise,'' in fact you find yourself
doing things inefficiently.
Can you please comment?
Mr. Curie. Yes, I can. I think those are excellent
questions. In short, the voucher program indeed will increase
capacity because on top of what is already being funded, we are
talking about an additional $200 million in the system.
Right now, we have two primary avenues that fund the
substance abuse and drug and alcohol treatment system in this
country. We have the Substance Abuse Prevention and Treatment
Block Grant, which totals about $1.8 billion, and with the
State match that is required throughout this country, $3.6
billion pretty much comprises that program. That has been the
foundation and backbone, if you will, of public drug and
alcohol treatment in this country since Medicaid, Medicare, and
other public funders do not fund substance abuse treatment to
any great extent.
So we are working to keep that block grant very much
intact. Again, we are working at developing performance
partnership measures with the States to build some further
accountability, but that will still be sustaining the
foundation of the drug and alcohol treatment structures.
We also have a second avenue called Targeted Capacity
Expansion Grants. That totals about $320 million, and that is
what I call our ``agility factor''--in other words, as we see
new and emerging trends emerge around the country, we are able
to fund specific programs to address those trends, and many
times, we bring to a larger scale interventions which are
purchased originally and funded by Targeted Capacity Expansion
Grants.
The Access to Recovery Program, the voucher program, is a
third avenue, and it does put in the mix using consumer choice,
but I think it needs to be stressed that we are looking at
structured choice. In other words, States will be responsible
for the voucher program as they are the block grant
implementation. And again, we are working with the States to
strengthen their role in the Targeted Capacity Expansion Grants
so that at the State level, they can work with local
communities to identify particular needs. The voucher program
needs to be managed at that level, and we are asking States to
credential providers, to make sure that there are clear and
informed choices being able to be made. And speaking as a
former provider myself, I also know that if consumers come and
clients come with resources in hand instead of me being
contained by perhaps a budget that is grant-funded, and I have
only a limited number of slots, I would have every motivation
to open up new slots with that additional funding stream.
So we are looking for increased capacity to be one of our
overriding goals.
Senator Reed. Thank you. That is a very, very appropriate
response, and this is a serious proposal, so I think we have to
ask serious questions. One factor in considering this proposal
is that we are dealing with a population of people who are
extremely vulnerable. I must confess that I have difficulties
making informed choices about health care providers and
different modes and modalities of treatment.
To assume that anyone can make these choices unaided is, I
think, unreasonable. And second, if you structure a program so
it is a voucher program, but it is essentially a voucher
program where a State official says, ``You have to go to XYZ
facility,'' that is not much different than what we have today.
The difference is that we are adding another degree of
uncertainty, in terms of who is the State official, what
programs they are going to direct people to, and what are their
criteria--is it what is best for their patient, or is it that
we have got to fill a need here, and this is a program we like
to see. Can you please explain?
Mr. Curie. Absolutely. Once the funds are appropriated, we
will be issuing a Request for Application to all 50 States.
There will be a competitive process in which States need to
demonstrate a capacity to be able to implement this voucher
program, and in that RFA which we are in the process of
developing, being informed by the field currently as well, we
are going to be setting out standards by which the States must
demonstrate that they will be giving real choice, that they
will be structuring the choice, and it is also going to be
based on the fact that an assessment has to take place in the
first place by a qualified professional who will assess and
determine the extent of need being presented to them.
So the choices that the individual will have will be within
a range of interventions of qualified providers who can provide
that type of services. So clearly, we are going to be expecting
States to show us that it is going to be structured, that they
have credentialing standards, that they are evaluating on an
ongoing basis, that they are looking at not only outcomes in
terms of whether people really are attaining recovery and
realizing those outcomes around employment, lack of involvement
in criminal justice, abstinence, and stabilized living
situation. If the State has that ongoing process, we are
confident that as the program is implemented, it will become
even more refined in terms of informed choices.
So there are going to be standards issued in this RFA;
States have to respond to that, but then we are going to give
States appropriate latitude in their implementation to make
sure that where they are implementing the voucher program, it
meets the needs of that State.
Senator Reed. Thank you.
There is another issue that will be involved in this
approach, and that is the issue of faith-based providers.
First, is it accurate to say that there are faith-based
providers today in programs that you are administering?
Mr. Curie. Yes.
Senator Reed. And they are operating under guidelines which
require them to have a separate corporate identity from their
religious identity, and that they follow local laws with
respect to civil rights; is that correct?
Mr. Curie. In many situations, that is the case, and again,
it varies from State to State what licensing requirements there
are. But what you have just described does exist.
Senator Reed. It does exist. It seems to me, though, that
obviously, there has been a push to say that religious entities
cannot operate with such ``restrictions,'' when in fact it does
work every day throughout the country. However, through these
efforts we will be into issues with respect to, separation of
church and State, whether you have the right to deny employment
to professionals because they do not agree with the creed or
aspects of the creed of the particular provider. And it strikes
me first that that is an issue you are going to have to wrestle
with seriously--we all are--but second, a model works today
that is allowing participation by faith-based organizations
through these mechanisms, and it is a model that I think is
effective, and we might be, for reasons unrelated to serving
people, trying to create a different approach.
Mr. Curie. Well, clearly, there are providers today who
have a faith-based orientation who are licensed and are
providing services today. We are also recognizing with Access
to Recovery that there are many pathways to recovery and that
if you have 200 people in recovery in this room, you will have
200 different stories of recovery, of where a person began to
achieve it and attain it. And very much with Access to
Recovery, we are looking to expand the array of services to
assure that not only is there perhaps an initial treatment
intervention but also many faith-based organizations that may
not be licensed today may be very good a relapse prevention, or
as people within recovery have also dealt with the spiritual
dimension of their lives, if they are looking at relapse, and
they come, and they are struggling with that and are assessed,
we want to be able to be assured that there are faith-based
options that are appropriate, and we are looking for all
providers, whether proprietary, nonprofit, community-based or
faith-based, they need to demonstrate functional outcomes in
people's lives. And I think that if we hold all providers
accountable with that being the common level of accountability,
we are not looking at church and State issues in terms of
identifying effective religions, but we are looking to identify
and purchase effective outcomes.
So we are gearing the standards toward that. We are asking
States to credential people appropriately. If they hang out
their shingle and say, ``I provide this kind of service,'' that
is a public safety and public health issue, and they need to be
credentialed and licensed according to that.
We are having discussions now with our current provider
base, we are having discussions with faith-based providers who
feel they have not had an opportunity necessarily to
appropriately participate in the array of services to determine
what are the appropriate standards depending on what that
provider says they do.
Senator Reed. The chairman has been most kind, and my time
has expired, but you are getting into one of the thorniest
thickets of constitutional, political, and cultural values that
we have in this country, and we should go in with our eyes
open.
If you are going to insist on credentialing, that raises
real questions of whether someone who has a religious vocation
and accreditation has to be credentialed as a substance abuse
professional to provide services. Many religions would say
absolutely not. Then, on the other side of the coin, is someone
who has a vocation and a theological degree automatically
credentialed as a substance abuse professional? Others would
say no--there is a different skill set here.
Let us just know that we are getting into the deep woods
here.
Mr. Curie. Agreed. I think the key right now is to have
ongoing dialogue, transparency in what the issues are, and
moving ahead in a way which clearly reflects the laws of the
land and clearly reflects accountability, clearly reflects the
fact that we want people to be able to make informed choices.
Senator Reed. Thank you, Mr. Curie. You have been very
responsive.
Mr. Curie. Thank you, Senator.
Senator DeWine. The President's Mental Health Commission
will soon make its final recommendation, so first, when is
their final report expected, and second, how will this report
affect the future direction of the agency?
Mr. Curie. The final report--very soon--in fact, before the
end of this month.
Senator DeWine. That is soon.
Mr. Curie. Yes, it is--and I have found that for the
Federal Government, that is very, very soon. It will be
presented before the end of the month, and we are very excited
about this. I know the Secretary and the President are very
much looking for this report to inform us as to how to address
mental health service delivery in this country. And the goals
that are set out in this report are going to parallel the goals
that we are seeing reflected as well in overall health care
transformation--for example, use of technology for self-care
and access will be a focus.
We also have a focus on needing early screening and
interventions and how to go about addressing that, and another
overall goal that recognizes that mental health is essential to
health; it is an overall health care issue.
So again, the interim report described a system that is
somewhat fragmented, at this point very fragmented, not
necessarily connected, has a nexus with criminal justice, with
education. And the attempt in this Commission report and then
the action plan that I anticipate will be developed that this
report will inform is to address that fragmentation so that we
have a clear, coherent policy around how public mental health
is delivered in this country, how we do it effectively in
partnership with the private sector, and how, bottom line,
children with serious emotional disturbance, adults with
serious mental illness, and their families have access and a
pathway to care so that they are not having to learn how to
navigate a system that is difficult to understand, but that the
system is one that basically morphs to their needs.
Senator DeWine. Well, I think we all have an obligation
both on the legislative and certainly from the executive side
to take those recommendations seriously, and I think we need to
be judged in 6 months, a year, or 2 years by how far we have
gone in implementing them.
Mr. Curie. Agreed.
Senator DeWine. Unfortunately, the history in Washington is
that we have reports and reports and reports, and they sit on
shelves, and if one percent of a report gets implemented, it is
a success. We need to do better than that.
Mr. Curie. Absolutely.
Senator DeWine. We have a lot of good people out there with
a lot of good ideas, and I think we have a real challenge here
to try to implement it.
We all agree that prevention is such an important part of
the comprehensive approach to drug and alcohol use and dealing
with this problem, and I must say I am troubled by the fact
that the administration for the past 2 years has requested less
funding for prevention programs. What is going on here?
Mr. Curie. That is a very good question. A little bit ago,
I introduced Beverly Watts Davis, who is our new director for
the Center for Substance Abuse Prevention. She has been on
board I believe for 6 weeks at this point.
Senator DeWine. Welcome.
Ms. Watts Davis. Thank you very much.
Mr. Curie. The good news with Beverly being aboard is that
she understands prevention programs from the ground up. And the
one thing that I need confidence in, the Secretary needs
confidence in as we move ahead with prevention is that we were
setting the stage for CSAP, if it is going to be the lead
Federal Agency for substance abuse prevention, to lead by being
able to articulate and work with the States, with the State
incentive grants, to ensure that we are moving toward what we
are calling a ``strategic framework for prevention.''
We know what works in prevention. We know the risk factors,
and we know protective factors that go with the risk factors.
And there are a lot of Federal programs that fund a range of
prevention types of programs. In HHS, we have ACF, the
Administration for Children and Families, we have the Centers
for Disease Control, we have HRSA, we also have SAMHSA,
obviously, we have Justice, we have Education, and other
departments' funding.
We believe it is imperative for CSAP not to just be funding
prevention program but to be garnering its efforts around
providing the leadership and framework to give States and then
communities the confidence that they are bringing their
coalition leaders to the table and that those leaders then are
helping to develop a plan based on need that is assessed, and
CSAP should be facilitating that.
I anticipate, and it should not be read--it does not
preclude that we are not looking for increasing resources to
CSAP as we move forward, but we also wanted to make sure that
as we looked at CSAP and assessed it that we were posturing it
to be able to use the dollars in a way that we were confident
that we were not just funding programs without that framework.
Senator DeWine. Well, I am not sure I understand your
answer. I do not want to be argumentative, but I think we all
agree that--and I am anxious to explore this with First Lady
Taft, because I have had the opportunity to read her testimony
about CSAP--we all agree that we want best science, and we all
agree that we should not fund things that do not work, we all
agree that we should fund things that do work, and we all agree
that we always need to keep doing more and more research. I
think we all agree on that.
But what else are you saying? I mean, we all agree on that.
Mr. Curie. Yes, yes.
Senator DeWine. No one wants to fund junk; we want to fund
good prevention. I have quite a bit of experience in this in
the area of Drug-Free Schools. I served on the National
Commission for Drug-Free Schools when I was in the House; I
have been through this in both the House and the Senate as a
legislator, and we have seen the bad experiences of funding a
lot of junk in the schools, and we hope that we are starting to
get away from that, and we are funding better stuff now.
It is the same way in the whole realm of prevention. There
is a lot of bad stuff out there to fund, and there is good
stuff out there to fund, and we have got to target our money
toward stuff that works, and we have got to measure what works.
OK. Now, having said all that, though, it still does not
get away from the fact that you have got to fund it, and it
still does not get away from the fact that once you identify
what is good, you have got to put money into it, and if you do
not put money into it, you do not get the job done.
So what am I missing here?
Mr. Curie. I believe that now we are positioned to have
confidence in terms of requesting new funding and sustaining
historic funding, that we can say that we are postured to make
sure that the money goes to what works.
In the past 2 years as we have looked at the overall budget
from SAMHSA, we have prioritized substance abuse treatment
looking at the guidelines in terms of resources, of where we
are putting our dollars. So I guess I want to go on record that
we are not precluding looking at future increases in prevention
as we move ahead. It is not a position that we do not support
prevention. We agree with you. We want to make sure that the
dollars are going in the right place. We need to structure
CSAP, and we have been in that process now, to make sure it can
clearly show a framework for funding in the future.
Senator DeWine. OK. First of all, do not misunderstand me.
I am not opposed--in fact I support increased funding for
treatment. So we are on the same page there.
Mr. Curie. Right. And these are tough decisions, too.
Senator DeWine. I know. I understand that, I understand
that. But I want to make sure I understand where you think you
are with CSAP. I get the impression that you think CSAP was not
where it should have been.
Mr. Curie. Exactly.
Senator DeWine. OK. CSAP was not where it should have been.
Tell me where it was, tell me where it is now, and tell me
where it is going to be.
Mr. Curie. OK. My assessment is----
Senator DeWine. Because this is what we are doing with this
committee, so let us get it.
Mr. Curie. Oh, absolutely.
Senator DeWine. Let me make sure I understand where the
administration--where was CSAP, how bad was it, and why was it
bad; where is it now, and where is it going?
Mr. Curie. OK. What I want to say is that clearly in CSAP,
there has been a staff there of dedicated individuals who are
competent in the area of prevention. I think what has been
lacking there is a strong, clear strategy and framework of
moving the prevention field ahead, giving communities what they
need to have confidence that they are funding programs that
will work.
In terms of initiatives within CSAP, there were a lot of
different initiatives being funded through different divisions
within the Center, but they were not being tied together over
what we are trying to accomplish in terms of outcomes being
identified in the field.
Senator DeWine. Well, were they funding junk?
Mr. Curie. They were funding some good things, and they
were funding some things that did not necessarily demonstrate
it was working. So I would say----
Senator DeWine. They were funding bad things.
Mr. Curie. They were funding some bad things, yes.
Senator DeWine. OK. Are they funding bad things now?
Mr. Curie. I think they are funding less bad things as we
go along. As we look at it, we are in the process of assessing
that now.
Senator DeWine. Well, you guys are running the place.
Mr. Curie. I would say that we have made tremendous
progress in putting the dollars into what works. One of the
programs I point to in CSAP that I think is excellent is the
National Registry of Effective Prevention Programs, and we have
identified 50 programs that show excellent outcomes there that
can be replicated. Those are the types of programs we want to
put more and more of our dollars in as we identify them and
emerging promising practices.
And what we are doing now in CSAP in terms of where it is
going is assuring that there is a structure in place to assess
what is working and what is not working, to be able to jettison
what is not working quickly and more quickly, to be able to
embrace what is working, to bring it to scale, to give States
the information they need to be able to bring it to scale, to
give communities what they need to make those decisions. And
since we do have a lot of Federal agencies funding a lot of
prevention, one of CSAP's primary responsibilities should be
providing the leadership to the Nation and the leadership to
the field in terms of how to make those wise decisions at the
State and community level. That is where a lot of our focus is
shifting more and more, and I think making that kind of a
hallmark of SAMHSA as we move ahead will be important. I do not
think that was clear in the past, and it was very easy for
SAMHSA to be one of many Federal programs funding a range of
prevention programs. We want to move away from that.
Senator DeWine. OK.
Senator Reed?
Senator Reed. Mr. Chairman I think Senator Murray has some
remarks.
Senator DeWine. Senator Murray has joined us. Thank you.
Good morning.
Senator Murray. Thank you, Mr. Chairman. Good morning. I
appreciate the hearing and I am sorry for being late.
Senator DeWine. You can make an opening statement or you
can go right into questions.
Senator Murray. Thank you.
I will submit my statement for the record. I really
appreciate your having the hearing. I think it is really
important that we focus on mental health, and I know that
Senator Wellstone's long work on getting mental health parity
is something that all of us still want to see happen some day,
or I hope we all do.
Mr. Curie, I do appreciate your coming today, and I am
sorry I missed the earlier questions. I just have a few that I
want to focus on, because I am concerned that for a long time,
we have thought of mental illness and substance abuse as things
that only affect adults, and that adult-only bias has really
resulted in significant underfunding for pediatric mental
health treatment and juvenile mental health and substance abuse
treatment. For too many young people, not treating them means
they wind up in prison. That is sort of the way we slant things
right now, which is not the way I think we should be focused.
I know that SAMHSA has started to shift some resources to
children's services and treatment, but we have a long way to
go, and I wonder if you could update us on what you are doing
and what you see happening and some of the improved treatments
and options for children and young people.
Mr. Curie. Thank you, Senator. I do agree with you that I
think historically, as we look at the public mental health
system, because its history and focus came out of treating
individuals in State institutions who were primarily adults,
children's services have lagged.
I think that is changing. I think we do have more to do. If
you look at our Center for Mental Health Services, we have a
Systems of Care grant process, and at this point, I think we
are funding it at a little more than $50 million. Systems of
Care is an approach which brings together all child-caring
systems in a community--juvenile justice, education, mental
health, substance abuse--to make sure that a child's need is
met in a comprehensive plan, because you are right--many times,
children fall through different gaps in different systems, and
when they fall through those gaps, sometimes, unfortunately and
inappropriately, the juvenile justice system ends up treating
those adolescents. We want to make sure that that does not
happen.
The good news for our Systems of Care approach--it has been
reviewed by the parts process in terms of its effectiveness,
and it has been deemed moderately effective--I think the score
was 75--and we are developing a plan to help improve that
score, but I think it gives us a model for both future funding
out of SAMHSA as well as informing CMS in terms of appropriate
funding of services, and we are in a position to be able to
work with State mental health authorities and Medicaid
authorities to talk about these programs which really are
bringing forth results.
Also, we spoke about the Mental Health Commission a moment
ago--there is going to be a strong focus there on children in
terms of developing a mental health action plan that address
prevention, early intervention, working with schools where the
children are in terms of identifying. We know that if we
intervene earlier, we can have much more positive results and
perhaps avoid a chronic disability around mental illness, and
we want to bring those things to scale as well.
So we have many initiatives around children's mental health
at this point, and I think we are poised to really work with
especially the public financing to assure that incentive are
put in the right place.
Senator Murray. Do you know what any of the States are
doing with their block grant money specifically to improve
services for children?
Mr. Curie. Again, with the block grant--and on the mental
health side of things, that typically comprises about one
percent of a State's mental health revenue--many States have
used those dollars because they have given them more
flexibility to prioritize children. And you find school-based
programs being funded in partnership with schools----
Senator Murray. To provide personnel at schools, for
example?
Mr. Curie. Yes, there are models like that, and there are
many States that use block grant moneys to fund those types of
programs. I think the struggle has always been--and speaking as
a former commissioner from Pennsylvania--the programs that we
fund have typically been on a smaller scale than we would like;
we see it working in a lot of areas, and the challenge has
always been how we bring to scale some of these school-based
interventions.
And again, with the block grant dollars being such a small
part of the overall revenue, it is a matter of how can we
leverage the block grant when we find these promising
practices, also our Targeted Capacity Expansion Grants, and
bring them into the mainstream of funding. I think that is
going to be one of our biggest challenges coming out of the
Mental Health Commission at this point.
Senator Murray. I know that SAMHSA does not directly
oversee any research, but research is another area that
concerns me, that we focus on an adult population, and a lot of
new treatments for mental illness do not have pediatric labels
or indications. Can you share with us anything that you know
about what is being done to do better research for children and
mental health?
Mr. Curie. I do know that the Institutes are looking
specifically at children, and research around that area. In
fact, I am being briefed within a week in terms of a science-
to-services initiative that we initiated out of SAMHSA in
collaboration with NIH, and both Dr. Zerhuni and I will be
briefed in terms of concrete products that are coming out of
that initiative, and children will be a particular part. We are
looking at children as well as adults as well as the aging
population, needing to focus on those three segments in
particular, not only in service delivery, but being informed by
services research.
I might add that part of what we need to be doing as well
is, once we identify a services research agenda, we have got to
think about how we unclog the pipeline, so to speak, of getting
the findings to practice, because that lag time is way too
long. So that is another aspect we need to be examining.
Senator Murray. Thank you very much. I really appreciate
it.
Mr. Curie. Thank you, Senator.
Senator Murray. Thank you, Mr. Chairman.
[The prepared statement and questions of Senator Murray
follows:]
Prepared Statement of Senator Murray
Mr. Chairman, I want to thank you and the Ranking Member
for scheduling this important hearing.
I'm pleased that we have elevated Mental Health and
Substance Abuse to a separate subcommittee within HELP. That's
appropriate because the need to increase our focus on mental
health and substance abuse has never been greater.
As we move to reauthorize the Substance Abuse and Mental
Health Services Act, I hope we can continue to work together
because a comprehensive reauthorization bill is in all of our
best interests.
I think we can all agree that our mental health and
substance abuse treatment infrastructure lacks any real
coordination. We also know that the demands for services far
outweigh the availability of effective treatment options.
I believe this is due--in part--to the lack of Mental
Health Parity in the private insurance arena. The inability to
treat mental illness the way we treat physical illness has
resulted in a fragmented treatment structure. It has also
created a shortfall in the availability of services.
Mr. Chairman, we would not accept these types of shortages
in any other healthcare field. Can you imagine a 6 month delay
in surgery due to a lack of providers or hospitals performing
surgery? Can you imagine being told that your child needs sinus
or orthopedic surgery but there is a 6 to 9 month waiting
period?
It would be unacceptable, but that's what many families
face when they need mental health or substance abuse treatment
services.
We need to stop thinking about mental health or substance
abuse treatment as something separate from physical health, and
we need to pass Mental Health Parity. Not only is it the right
thing to do, but it would be a fitting tribute to our former
colleague Paul Wellstone.
Questions of Senator Murray for Panel I--Dr. Charles Curie,
Administrator, SAMHSA
Question 1. For too long, we have thought of mental illness and
substance abuse as things that only affect adults. This ``adult only''
bias has resulted in significant under-funding for pediatric mental
health treatment and juvenile mental health and substance abuse
treatment. Tragically, when young people don't get the help they need,
they fall through the cracks.
For too many young people, prison is becoming the provider of last
resort for juvenile mental health and substance abuse treatment.
Clearly we are failing our children. I know that SAMHSA has begun to
shift greater resources to children services and treatment, but we
still have a long way to go.
I'm interested in your efforts to continue to improve services and
treatment options for children regarding mental health and substance
abuse.
I would also be interested in what the states are doing with block
grant moneys to improve services for children and adolescents.
Because of the ``adult bias'' in mental illness and substance
abuse, mental health research involving children has also lagged
behind, and the gap continues to grow. Many new treatments for mental
illness still do not have pediatric labeling or indications. I realize
that you are not directly involved in mental health research, but as
the Administrator of SAMHSA I know you are aware of research efforts at
NIH.
Could you provide an update on pediatric and adolescent mental
health research?
Questions of Senator Murray for Panel I and II
Question 1. What can we do in reauthorizing SAMHSA to improve
access to treatment options for children? Is it a matter of money? Or
do we need to do more to expand the block grant?
I know that report after report has shown that there is little
coordination between providers and systems responsible for providing
treatment and services to individuals with mental illness.
These problems are only intensified for children. Too many children
are simply falling through the cracks and spending their adult years in
prison.
Question 2. We are seeing significant delays in diagnosing and
treating mental illness in rural communities. Almost every county in
Washington State has been designated a Mental Health Professions
Shortage Area. There are simply not enough mental health providers to
diagnosis and treat mental illness. Undiagnosed mental illness often
results in greater physical health costs and many other social problems
like homelessness, family violence and substance abuse.
Question 3. What can we do to provide greater coverage in rural
areas? One of the most promising options appears to be telehealth.
Question 4. Can we use the reauthorization of SAMHSA to expand
telehealth opportunities in mental health treatment?
I know in Washington State several demonstrations are ongoing and
offer real promise using telehealth as a means to expand access to
mental health services.
Question 5. Can you provide any insight into the possibilities of
telehealth technology to address the major shortage of mental health
providers?
Senator DeWine. Thank you very much. It is been very good
testimony, very, very helpful. You have a very big job, a very
important job, and we look forward to working with you as we
move forward on the reauthorization.
Mr. Curie. Thank you, Mr. Chairman, and thanks for your
support.
Senator DeWine. We appreciate it. Thank you. We will be
here to support you.
Let me ask the second panel to come up now as I introduce
them.
First, Hope Taft is the First Lady of Ohio. She is a
tireless advocate of substance abuse prevention services. Mrs.
Taft is the co-founder of several anti-drug organizations,
including Ohio Parents for Drug-Free Youth and the Ohio Alcohol
and Drug Policy Alliance, and is an Ohio Certified Prevention
Specialist II. Mrs. Taft was appointed by the President to
serve on the President's Council on Service and Civic
Participation. She serves on the National Advisory Council of
the Center for Substance Abuse Treatment, the National Advisory
Council on Alcohol Abuse and Alcoholism, and on the National
Conference of State Legislators' Advisory Committee on the
Treatment of Alcoholism and Drug Addiction. From 1998 to 2003,
Mrs. Taft served as a member of the President's Commission for
Drug-Free Communities.
Dr. Lewis Gallant is executive director of the National
Association of State Alcohol and Drug Abuse Directors. He has
served as executive director since November 2000. Prior to his
current position, he served as vice president and president as
well. Dr. Gallant came to the National Association of State
Alcohol and Drug Abuse Directors from the Virginia Department
of Mental Health, Mental Retardation and Substance Abuse
Services, where he worked for 8 years and where he was most
recently director of the Office of Substance Abuse Services. He
also spent 20 years in active military service as human
services manager and administrator in the U.S. Army Medical
Department.
Martha Knisley joins us from the District of Columbia's
Department of Mental Health. Ms. Knisley is the first director
of the D.C. Department of Mental Health. She has worked for
three decades as a mental health clinician and administrator.
She directed two State departments of mental health--
Pennsylvania and Ohio. Prior to becoming director in Ohio, as
deputy director, she helped build Ohio's Statewide Community
Mental Health System. Prior to coming to the District, she was
a senior consultant with the Technical Assistance Collaborative
created by the Robert Wood Johnson foundation to assist State
and local governments manage their public mental health
systems.
Ms. Gloria Walker, our final panelist, is joining us from
Cincinnati. Ms. Walker is president and owner of GW Consulting
and Education Services. She has taught in the Cincinnati public
schools and served as a professor at the University of
Cincinnati and Southern Ohio College. Ms. Walker is a member of
the board of directors of the National Alliance for the
Mentally Ill and has also served as board president for NAMI
Ohio. Ms. Walker is also a member of the National Association
of Mental Health Planning and Advisory Council and the mother
of a child diagnosed with schizophrenia and bipolar disorder.
We thank all of you for taking your very valuable time to
come here and be with us. We will start with Mrs. Taft.
Thank you very much. We have your prepared testimony. It
will be made a part of the record, and if each of you could
confine your testimony to 5 minutes and summarize your
testimony, we would appreciate it. That will give us the
opportunity to ask questions.
Mrs. Taft?
STATEMENTS OF HOPE TAFT, FIRST LADY OF OHIO; LEWIS E. GALLANT,
EXECUTIVE DIRECTOR, NATIONAL ASSOCIATION OF STATE ALCOHOL AND
DRUG ABUSE DIRECTORS, INCORPORATED; MARTHA B. KNISLEY,
DIRECTOR, DEPARTMENT OF MENTAL HEALTH, DISTRICT OF COLUMBIA, ON
BEHALF OF THE NATIONAL ASSOCIATION OF STATE MENTAL HEALTH
PROGRAM DIRECTORS AND THE CAMPAIGN FOR MENTAL HEALTH REFORM;
AND GLORIA WALKER, MEMBER, BOARD OF DIRECTORS, NATIONAL
ALLIANCE FOR THE MENTALLY ILL
Mrs. Taft. Thank you, Chairman DeWine and Members of the
Committee, for this opportunity to talk about substance abuse
prevention in the context of the SAMHSA reauthorization.
I bring thanks from Ohio's alcohol and drug treatment and
prevention field to you, Senator DeWine, for your outstanding
commitment, dedication, and leadership in protecting and
enhancing the Federal role of alcohol and drug prevention and
treatment.
I feel strongly that prevention has been underutilized in
both funding and emphasis and has not reached its potential
relative to its importance and effectiveness in reducing drug
and alcohol use and their related human and societal costs.
In my time before you, I would like to emphasize several
point. First, prevention is effective; it is worth the
investment. The Center for Substance Abuse Prevention, or CSAP,
is vital to local efforts, and it should stay separate from
treatment, just as the alcohol and drug prevention and
treatment fields should stay separate from the mental health
field.
My second point is that Congress can help. It can help the
Nation by keeping CSAP a distinct entity. It can help the
Nation by keeping CSAP's funding stable and sustained. And
Congress can help by encouraging CSAP's current direction of
building capacity, effectiveness, and accountability in the
field and its movement to environmental community-based
approaches.
Finally, Congress can help by making sure that CSAP's
success is measured and based on what CSAP funds and can
control.
Since the mid-1980's, when I began my career as a certified
prevention specialist working in Cincinnati, OH, I have
experienced first-hand both the devastation that substance
abuse has on families and communities as well as the power of
effective prevention strategies in reducing the use of alcohol
and illegal drugs.
From 1993 to 2000, there was a 41 percent decrease in
marijuana use among 7th to 12th graders living in communities
with coalitions associated with the Coalition for a Drug-Free
Greater Cincinnati. In the same region over the same time
period, where a substance abuse prevention coalition did not
exist, there was a 33 percent increase in marijuana use.
As a Nation, we must make a sustained and substantial
investment in delaying the age at which American youth start to
use alcohol and illegal drugs. Research has found that people
who begin drinking before the age of 15 are four times more
likely to develop alcohol dependence than those who have their
first drink at age 21 or older. And children who first smoke
marijuana under the age of 14 are more than five times as
likely to abuse drugs as adults than those who first use
marijuana at age 18.
One of the most important indicators of the number of
people who will need treatment is the age of first use of
marijuana. Studies show that if we can immediately reduce the
number of initiates into drug use by 25 percent, we can reduce
the number who need treatment by one million people.
Effective substance abuse prevention efforts can pay major
economic dividends. A soon-to-be-released study called ``The
Cost-Benefit Estimates in Prevention Research,'' by Dr. John
Swisher, finds that the savings per dollar spent on substance
abuse prevention can be substantial and range from $2 to
$19.64, depending on how the costs were calculated, the
outcomes indicated, and differences in methodologies.
Although there is a widely-held view that the use of
alcohol and illegal drugs is normal adolescent behavior among
American youth, and that not much can really be done to prevent
it, the latest statistics from major surveys in both Ohio and
nationally tell a different story. Nationally, data show a
significant downturn in youth drug use, with students in all
grades showing a decline in prevalence. These findings show
that drug prevention efforts are working.
With drug use by our Nation's youth dropping after almost a
decade of increases, SAMHSA's reauthorization offers an
important opportunity to sustain and accelerate this downward
trend. There are ways that Congress can help keep the Nation's
prevention efforts strong and our children's future bright
through the reauthorization of SAMHSA.
The 20 percent set-aside in the Substance Abuse Prevention
and Treatment Block Grant is the largest funding source
dedicated exclusively to substance abuse prevention in States
and communities throughout the Nation. It is imperative that
this set-aside be maintained in the SAMHSA reauthorization.
The State Incentive Grants are another important source of
funding now in 41 States, with the goal of being in all 50
States. The programs are aimed at filling the gaps in community
prevention services, reducing the number of youth using drugs,
and implementing prevention approaches that are based on sound
scientific research findings.
If these funding sources become more stable and
predictable, the field would be better able to build a
coordinated approach of effective prevention strategies.
The most effective substance abuse prevention is
comprehensive and community-wide and includes environmental
strategies that are designed to change and strengthen norms
regarding alcohol and drug use. The SAMHSA reauthorization
needs to help refocus the emphasis of substance abuse
prevention from mostly individual behavioral-based programs to
comprehensive community-wide strategies that more effectively
address youth drug and alcohol use as current research
suggests.
I want to thank Administrator Curie for his leadership in
developing a strategic prevention framework within SAMHSA. This
framework focuses on a science-to-services and strategy
approach which recognizes CSAP's unique role as the lead
Federal agency for substance abuse prevention. CSAP's
expertise, materials, and services should be utilized by other
Federal agencies that deal with substance abuse prevention to
avoid duplication of effort and to maximize the utilization of
Federal funds in developing, delivering, and evaluating
effective substance abuse prevention at the State and local
levels.
Effective substance abuse prevention needs to be data-
driven, comprehensive, and sustained over time. CSAP should be
encouraged to continue to take the lead in developing, funding,
and sustaining a bona fide substance abuse prevention system
throughout the Nation. This system should define and support
the roles, responsibilities, infrastructure, and capacity
needed at the Federal, State, and local levels to increase the
number of youth who do not use and, of those who do, increase
the age of first experimentation.
CSAP's success should be measured on what it funds and can
control. Local prevention efforts receive funding from a
variety of sources. Many communities have a lot of financial
resources while others have very few. Yet it seems like one
funding source or another is blamed for the rise in alcohol or
other drug use and is never given credit for reductions that
happen in a global sense.
It would be wonderful if Congress could encourage the
hastening of the time when success was based on efforts over
which a funding source had control. This subcommittee's work is
vital and will shape the direction of prevention and treatment
efforts for many years to come. In fact, your decisions will
shape the future of this country.
New research is showing that young people who abuse alcohol
may remember 10 percent less than their peers who do not use.
Children are the future, and we must do everything we can to
invest in keeping them the best and the brightest in the world
so they can secure the United States' place as a leader in the
global knowledge economy.
I thank you for this opportunity to speak to you, and I
welcome questions.
Thank you.
Senator DeWine. Thank you very much.
[The prepared statement of Mrs. Taft follows:]
Prepared Statement of Hope Taft
Chairman DeWine, Ranking Member Kennedy, and other distinguished
Committee Members, thank you for the opportunity to testify about the
importance of substance abuse prevention in the context of SAMHSA
reauthorization. Before I begin, I would like to take a moment to
formally thank my good friend, Senator Mike DeWine, for his outstanding
commitment, dedication and leadership in protecting and enhancing the
Federal role in alcohol and drug prevention and treatment.
While I fully understand and support the importance of substance
abuse treatment services, I feel strongly that prevention has been
under utilized, regarding both funding and emphasis, and thus not
reached its potential, relative to its importance and effectiveness in
reducing drug and alcohol use and their related human and societal
costs.
To that end, today I want to emphasize several points. The first
being prevention is effective. It is worth the investment. The Center
for Substance Abuse Prevention (CSAP) is vital to local efforts and it
should stay separate from treatment, just as the alcohol and drug
prevention and treatment field should stay separate from the mental
health field.
My second point is that Congress can help. It can help the Nation
by keeping CSAP a distinct entity. It can help the Nation by keeping
CSAP's funding stable and sustained. Congress can also help by
encouraging movement to environmental community-based approaches and by
encouraging CSAP's current direction of building capacity,
effectiveness and accountability in the field. Finally, Congress can
help by making sure that CSAP's success is measured based on what CSAP
funds and can control.
Since the mid 1980's, when I began my career as a certified
prevention specialist working in Cincinnati, Ohio, I have experienced
first hand, both the devastation substance abuse has on families and
communities as well as the power of effective prevention strategies to
reduce the use of alcohol and illegal drugs. I have also seen the
substance abuse prevention field mature from the ``treatment model''
phase of it's infancy, to the data driven, strategic, multisector
efforts, that are achieving outcomes in communities throughout Ohio and
across the Nation. For example, there are greater reductions in
adolescent substance use in communities with comprehensive substance
abuse prevention coalitions, than in communities where these coalitions
do not exist. From 1993 to 2000, there was a 41 percent decrease in
marijuana use among 7th to 12th graders, living in communities with
coalitions associated with the Coalition for a Drug-Free Greater
Cincinnati. In the same region, over the same time period, where a
substance abuse prevention coalition did not exist, there was a 33
percent increase in marijuana use.
Every new cohort of youth must have the benefit of effective
substance abuse prevention. As a Nation, we must make a sustained and
substantial investment in delaying the age that American youth start to
use alcohol and illegal drugs. Research confirms that early alcohol and
drug use can have long-lasting and expensive consequences. Research by
the National Institute on Alcohol Abuse and Alcoholism (NIAAA) has
found that people who begin drinking before the age of 15 are four
times more likely to develop alcohol dependence, than those who have
their first drink at age 21 or older. According to findings from the
National Household Survey, children who first smoke marijuana under the
age of 14 are more than five times as likely to abuse drugs as adults,
than those who first use marijuana at age 18.
In 1999, I came across some information that convinced me we need
to focus even more of our efforts on prevention--I read how the
treatment of addictions is really a growth industry. By the year 2020,
the need for alcohol and other drug treatment will increase by 57
percent.
I also read that one of the most important indicators for the
number of people who will need treatment in 2020 is the age of first
use of marijuana. Currently, the age of first use of marijuana is about
13. Studies show that if we can immediately reduce the number of
initiates into drug use by 25 percent, we can reduce the number who
need treatment by one million. There's a real need to think about how
we can help our young people grow up in a healthy way.
Effective substance abuse prevention efforts can pay major economic
dividends. A soon to be published study in the Journal of Primary
Prevention on ``Cost-Benefit Estimates in Prevention Research'' by John
D. Swisher, PhD. and his colleagues, finds that, and I quote ``the
savings per dollar spent on substance abuse prevention can be
substantial and range from $2.00 to $19.64 depending on how costs were
calculated, outcomes included and the differences in methodologies.''
Although there is a widely held view that the use of alcohol and
illegal drugs is normal adolescent behavior among American youth, and
that not much can really be done to prevent it, the latest statistics
from major surveys both in Ohio and nationally tell a different story.
The latest PRIDE survey released in Ohio last year, found that the use
of alcohol, tobacco and illegal drugs by youth has declined
substantially over the past 3 years. For instance, illicit drug use
among Ohio teens decreased 21 percent since 1999, with a 16 percent
decrease across the U.S. Alcohol use was down 16 percent, compared to a
12 percent reduction in use nationwide. Ohio's student tobacco use
decreased 38 percent compared to 14 percent across the Nation.
Nationally, data from the most recent ``Monitoring the Future''
survey show a significant downturn in youth drug use, with students in
all grades showing declines in prevalence. These findings show that
drug prevention efforts are working. With drug use by our Nation's
youth dropping after almost a decade of increases, SAMHSA
reauthorization offers an important opportunity to sustain and
accelerate this downward trend.
As a substance abuse prevention specialist II, a volunteer
community leader, and as the First Lady of Ohio, CSAP has been an
invaluable source for the materials, tools and resources I have needed.
CSAP has the ability to do many things those of us at the local level
cannot. It can bring together the best minds in the Nation to develop
programs and strategies based on the best research and provide
technical assistance. It can do sophisticated evaluation studies of
programs and approaches to prevention. It can develop materials and
tools that are research based and tested for effectiveness. I firmly
believe that CSAP must not only be maintained as a discrete entity
within SAMHSA, but that its role needs to be strengthened and enhanced
in SAMHSA reauthorization.
There are ways Congress can help keep the Nation's prevention
efforts strong and our children's future bright through the
reauthorization of SAMHSA.
Maintain CSAP's Funding Streams Including the 20 Percent PreventionSet-
Aside in the Block Grants, State Incentive Grants (SIG) and all Other
Funding Categories
The 20 percent set-aside in the Substance Abuse Prevention and
Treatment Block Grant is the largest funding source dedicated
exclusively to substance abuse prevention in States and communities
throughout the Nation. It is imperative that this set-aside be
maintained in SAMHSA reauthorization. I would suggest, however, that
States be encouraged to target more of these resources into building
comprehensive, high quality and stable community-based infrastructures,
based on the latest research. This will facilitate the consistent
application of effective substance abuse prevention strategies,
programs and activities in many more communities across the country.
The State Incentive Grants are another important source of funding,
now in 41 States, with the goal of being in all 50 States. The programs
funded by these grants serve over 5 million people and are aimed at
filling the gaps in community prevention services, reducing the number
of youth using drugs and implementing prevention approaches that are
based on sound, scientific research findings.
If these funding sources become more stable and predictable, the
field would be better able to build a coordinated approach of effective
prevention strategies.
Emphasize Environmental Strategies
The most effective substance abuse prevention is comprehensive and
community-wide and includes environmental strategies that are designed
to change or strengthen norms regarding alcohol and drug use.
Environmental strategies involve changes in legislation, policy and
enforcement throughout an entire community, to directly address youth
access to drugs and alcohol as well as the consequences for use. SAMHSA
reauthorization needs to help refocus the emphasis of substance abuse
prevention from mostly individual, behaviorally based programs to
comprehensive community-wide strategies that more effectively address
youth drug and alcohol use.
Emphasize Strategic Framework for Prevention
I want to thank Administrator Curie for his leadership in
developing a strategic prevention framework within SAMHSA. This
framework focuses on a science-to-strategy approach, which recognizes
CSAP's unique role as the lead Federal agency for substance abuse
prevention. CSAP's expertise, materials, and services should be
utilized by other Federal Agencies that deal with substance abuse
prevention, such as the Department of Education's Safe and Drug Free
Schools and Communities Program. This will avoid duplication of effort
and maximize the utilization of Federal funds in developing, delivering
and evaluating effective substance abuse prevention at the State and
local levels so effective substance abuse prevention is brought to
every community.
Emphasize Infrastructure and Capacity Development
CSAP's limited resources need to be focused on building and
strengthening State and local infrastructure and capacity for
implementing effective substance abuse prevention strategies, programs
and activities.
Effective substance abuse prevention needs to be data driven,
comprehensive, and sustained over time. CSAP should be encouraged to
continue to take the lead in developing, funding and sustaining a bona
fide substance abuse prevention system throughout the Nation. This
system should define and support the roles, responsibilities,
infrastructure and capacity needed at the Federal, State and local
levels to increase the number of youth who do not use and of those who
do, increase the age of first experimentation.
CSAP's Success Should Be Measured on What it Funds and can Control
Local prevention efforts receive funding from a variety of sources
including Drug Free Community grants from the Office of National Drug
Control Policy (ONDCP), Safe and Drug Free School Funding from the
Department of Education and State and local financial support of which
CSAP has no control. Some communities have a lot of financial resources
while others have very few. Yet it seems like one funding source or
another is blamed for the rise in alcohol or other drug use and is
never given credit for reductions that happen in the global sense. It
would be wonderful if Congress could encourage the hastening of the
time when success was based on efforts over which a funding source had
control.
This subcommittee's work is vital and will shape the direction of
prevention and treatment efforts for many years to come. In fact your
decisions will shape the future of this country. New research is
showing that young people who abuse alcohol may remember 10 percent
less than their peers who do not use. Children are the future and we
must do everything we can to invest in keeping them the best and the
brightest in the world so they can secure the United States' place as
the leader in the global economy.
Thank you for the opportunity to testify before your subcommittee.
I would be happy to answer any questions you may have.
Senator DeWine. Dr. Gallant?
Mr. Gallant. Mr. Chairman and Members of the Subcommittee,
I am Lewis Gallant, executive director of the National
Association of State Alcohol and Drug Abuse Directors, or
NASADAD.
Thank you for calling this hearing and for seeking our
input. NASADAD members are the lead officials in each State who
oversee and manage public substance abuse prevention and
treatment systems. We look forward to working with you and the
rest of the committee on legislation to reauthorize SAMHSA.
Along with this committee and my fellow panelists, I know how
other partners, many of whom are here today, stand ready and
excited to work together on these issues.
Mr. Chairman, I would like to commend you for your
commitment to improve the lives of those who suffer from
addiction. I would also like to recognize Senator Kennedy and
thank him for his steadfast dedication to these issues as well.
Together, you both have been true leaders and true friends of
the field.
Another leader is Mr. Charles Curie, administrator of
SAMHSA. Mr. Curie is energetic, knowledgeable, and innovative,
and he has made outreach to NASADAD a top priority.
This is certainly an exciting time, in large part because
President Bush has made substance abuse prevention a national
priority. During his State of the Union Address, he told the
Nation that recovery is real, and treatment works. With this
powerful message, the President has dedicated substantial
resources to increasing our Nation's capacity to treat those
suffering from addiction. We are grateful for these resources
and do not take for granted his personal commitment to this
issue.
I have submitted a more detailed written statement to the
committee regarding reauthorization. Today I would like to
focus on a few key areas.
A top concern for NASADAD is the Substance Abuse Prevention
and Treatment Block Grant. A block grant is an efficient and
effective program that participates in maintaining a foundation
for their respective service delivery systems. As we consider
SAMHSA reauthorization, a top priority for NASADAD is the
transition from the current block grant to a Performance
Partnership Grant, or PPG. The transition is designed to
provide States more flexibility in the use of funds while
instituting a system of improved accountability based on
performance.
While NASADAD supports the goals of this transition, there
are key issues requiring attention. First, data infrastructure
development and management are the basic ingredients for
success in our efforts to plan for and implement the PPG.
Substantial resources are needed to help States build systems
that will collect, track, refine, manage, analyze and
disseminate data in accordance with the anticipated new
reporting and other requirements.
In addition to resources, NASADAD is concerned with the
timing of the transition to PPG. Some have suggested, for
example, that performance measurement should begin as early as
fiscal year 2004. NASADAD recommends that any change in the
block grant application, and thus the reporting and
implementation of performance measures, begin after the
following prerequisites move forward: first, the consideration
of a report to Congress discussing the transition to PPG,
including the flexibility that States need, potential obstacles
to PPG, resources required, data to be collected, and any
recommended legislative language; second, an assessment by the
Secretary of Health and Human Services of the States' readiness
to report PPG data as required by the Children's Health Act of
2000; third, the allocation of new and additional resources to
assist with data, infrastructure, and other administrative
costs, and a process whereby legislation is passed by Congress
and signed by the President that reflects an agreement that
incorporates the input of the NGA, NASADAD, and others.
As my time is short, I would like to simply list two other
issues to highlight. First, as mentioned by Mr. Curie, NASADAD
views policies impacting those with co-occurring substance use
and mental health disorders as top priorities.
Very quickly, NASADAD would ask that policy recommendations
flow from and be consistent with the collaborative work done by
NASADAD and the National Association of State Mental Health
Program Directors, who are also here today with testimony.
Finally, NASADAD believes that State systems must be
directly considered and involved in any SAMHSA grant program to
ensure that resources are distributed in coordination with
State planning processes. We believe, for example, that States
should be eligible to apply for Targeted Expansion Capacity
Grants and at the very least, to be signatories to all TEC
applications whether or not a State is an applicant.
In sum, we look forward to working with the committee,
SAMHSA, and other stakeholders on the reauthorization
legislation. Thank you again for seeking our input. I will be
happy to answer any questions that you may have.
Senator DeWine. Thank you, Dr. Gallant, very much.
[The prepared statement of Mr. Gallant follows:]
Prepared Statement of Lewis E. Gallant, Ph.D.
Mr. Chairman, Ranking Member Kennedy, and Members of the
Subcommittee, my name is Dr. Lewis Gallant and I am the Executive
Director of the National Association of State Alcohol and Drug Abuse
Directors (NASADAD). First, I would like to recognize you, Mr.
Chairman, for your leadership in helping millions of people across the
country with addiction problems. The substance abuse field truly
appreciates your dedication and commitment to these issues. In turn,
thank you for calling this hearing to discuss the reauthorization of
the Substance Abuse and Mental Health Services Administration
(SAMHSA)--the Nation's lead Federal agency on addiction and mental
health. We sincerely appreciate your outreach to States and look
forward to working closely with you and the Subcommittee. I would also
like to recognize the Ranking Member, Senator Kennedy, for his tireless
efforts to improve our Nation's substance abuse system. Thank you for
your work and valuable leadership. Finally, I would like to thank the
other members of this Subcommittee. I look forward to working with you.
President Bush: Substance Abuse Services Must Be a National Priority
I would like to commend the President for his personal commitment
to substance abuse issues. NASADAD is extremely grateful that President
Bush identifies addiction as a top priority and is moving forward to
elevate addiction treatment and prevention issues to the forefront of
our national agenda.
We do not take for granted, at all, the significance of the
President's leadership, and the leadership of Mr. Charles Curie,
Administrator of SAMHSA, and Mr. John Walters, Director of the Office
of National Drug Control Policy (ONDCP). We do not take for granted the
President's action to dedicate substantial resources to close the
treatment gap. In particular, the President moved forward to dedicate
an additional $1.6 billion over 5 years for substance abuse treatment.
This has included significant increases to the Block Grant, his
proposed ``Access to Recovery Program,'' and other initiatives. Indeed,
this is historic.
Nor do we underestimate the power of the bully pulpit. We are very
fortunate that the President is using this bully pulpit--this national
stage--to share with the American public a simple yet extremely
powerful message: substance abuse prevention and treatment works.
As the President once noted, ``In this struggle, we know what
works. We must aggressively and unabashedly teach our children the
dangers of drugs. We must aggressively treat addiction wherever we find
it. And we must aggressively enforce the laws against drugs at our
borders and in our communities . . . America cannot pick and choose
between these goals. All are necessary if any are to be effective.'' I
could not agree more.
We are also pleased that the President has surrounded himself with
leaders in his Administration who truly care about substance abuse and
are working to make a difference. We heard today from Mr. Charles
Curie, Administrator of SAMHSA. It has been a pleasure to work with Mr.
Curie over the past few years. Administrator Curie is an energetic,
knowledgeable and innovative leader. As a former State official, Mr.
Curie has made outreach to NASADAD a top priority. Mr. Curie has met
with NASADAD's Board on a number of occasions, attended our Annual
Meetings, held systematic meetings with me as Executive Director, held
meetings with our members and much, much more. Mr. Curie and his staff
have worked very hard to listen to the concerns of States. We
appreciate this outreach and believe this partnership will continue to
remain strong.
I would like to acknowledge the excellent work of Tommy Thompson,
Secretary of the Department of Health and Human Services (HHS). As a
former Governor, he knows first hand the challenges States face in
providing services to those with addiction problems. Secretary Thompson
has been relentless in his promotion of helpful policies related to
substance abuse.
NASADAD would also like to thank ONDCP Director John Walters for
his work and leadership. Director Walters has been tireless in laying
out a path to meet the President's goals of reducing illegal drug use
by 10 percent over 2 years and 25 percent over 5 years. In the process,
Mr. Walters has been reminding us all to ``push back'' against those
who promote drug use and experimentation as a normal part of life.
Scope of Addiction in the U.S.
Addiction has a devastating impact on our society. SAMHSA's 2001
National Household Survey on Drug Abuse (NHSDA) found that an estimated
16.6 million persons age 12 or older were classified with substance
dependence on or abuse. The survey noted that of these 16.6 million
persons, 2.4 million were classified with dependence or abuse of both
alcohol and illicit drugs, 3.2 million were dependent or abuse illicit
drugs but not alcohol, and 11 million were dependent on or abused
alcohol but not drugs. The number of persons with substance dependence
or abuse increased from 14.5 million in 2000 to 16.6 million in 2001.
Projections in drug abuse treatment need made by the NHSDA are
extremely compelling. Specifically, the study found that if current
initiation rates continue at the same levels we are experiencing now,
demand for drug treatment will more than double (an increase of 57
percent) by 2020. Even if we managed to cut current initiation rates by
50 percent, demand for treatment would simply remain constant. Needless
to say, we must work together to step up our prevention efforts. In
addition, efforts must be made to expand access to substance abuse
treatment services.
Addiction is an equal opportunity disease that does not
discriminate by age, gender or race. For example, the NHSDA found that
10.8 percent of youths ages 12 to 17 were current drug users in 2001.
Another study by SAMHSA found that there is an ``invisible epidemic''
taking place among our senior citizens, where an estimated 17 percent
of our seniors have a substance abuse problem.
An acute problem is the link between substance abuse and our child
welfare system. Research has found that 70 percent of families with a
child in protective care struggle with addiction.
The disease of addiction has a huge economic impact on our country.
Studies have shown that alcohol and other drug addiction cost the
Nation as much as $400 billion per year. These costs stem from lost job
productivity, health care needs, crime, accidents, welfare and child
welfare and other factors.
But of course no statistic or gross dollar estimate can ever
adequately capture the toll addiction takes on citizens and their
families each and every day. We all know a friend, family member, co-
worker or even celebrity impacted by substance abuse. As the President
said, ``Addiction crowds out friendship, ambition, moral conviction,
and reduces all the richness of life to a single destructive desire.''
Substance Abuse Treatment Works! Substance Abuse Prevention Works!
Although we face incredible challenges, tremendous gains have been
made over the years to help address the treatment needs of our Nation.
We know, for example, that criminal activity decreases by as much as 80
percent when treatment is administered. We know that infants whose
mothers receive substance abuse treatment avoid low birth weight,
premature delivery and death at rates better than the national average.
We know that welfare recipients who need addiction treatment, and
undergo a complete treatment cycle, are more likely to get a job and
earn more money than those who receive only minimal treatment services.
Simply put--we know treatment works.
We also know that prevention works. For example, we have seen that
federally funded substance abuse programs for ``high-risk youth'' yield
reduced rates of alcohol, tobacco and marijuana use. Prevention is also
cost-effective. A 2001 study by the Center for Substance Abuse
Prevention (CSAP) estimated a savings of up to $20.00 for each dollar
invested in prevention services.
There is no doubt that we must constantly strive to improve our
substance abuse system. In fact, Governors in States across the country
demonstrate this commitment as they implement innovative and exciting
initiatives addressing addiction. Legislation reauthorizing SAMHSA
provides us with an excellent opportunity to make important
improvements. With this in mind, I would like to highlight some key
themes as we begin to examine SAMHSA reauthorization.
SAPT Block Grant: The Foundation of Our Addiction System
The Substance Abuse Prevention and Treatment (SAPT) Block Grant is
a crucial program that assists States in maintaining a foundation for
their respective service delivery systems. In particular, Block Grant
funds help vulnerable populations--including youth and pregnant and
parenting women--who either have, or at risk of having, a substance
abuse problem. Also, the Substance Abuse Block Grant creates and
maintains linkages with other public programs to maximize the impact of
available resources.
These linkages are vital due to the competing year-to-year
pressures impacting State substance abuse systems. For example, States
across the country are facing severe budget cuts due to the economy,
homeland security costs related to the tragic events of September 11
and other issues. The National Governors' Association (NGA) and the
National Association of State Budget Officers (NASBO) recently
announced the results of the latest Fiscal Survey of the States.
Specifically, NGA & NASBO found that ``37 States were forced to reduce
already enacted budgets by nearly $14.5 billion--the largest spending
cut in the history of the 27-year-old Fiscal Survey.''
Recently, the Senate Appropriations Committee issued a report to
accompany the bill funding the Departments of Labor, Health and Human
Services (HHS), Education and Related Agencies (Senate Report 108-81).
The Report noted:
The Committee wishes to express its strong support for preserving
the current block grant and future PPG as the foundation of our
publicly funded substance abuse system in every State and territory in
the United States. Similarly, the Committee is concerned with any
effort that could erode the strength of the current and future block
grant. At a time when States are facing fiscal crises, with some
cutting substance abuse services, the maintenance of treatment
infrastructure and capacity at the local level is extremely important.
We believe this is an important pillar to keep in mind as SAMHSA
reauthorization is considered.
Transition from the Current Substance Abuse Prevention and Treatment
(SAPT) Block Grant to a Performance Partnership
Grant (PPG)
NASADAD views the transition from the current SAPT Block Grant to a
Performance Partnership Grant (PPG) as the top priority for SAMHSA
reauthorization. In fact, we would recommend a separate hearing on this
vital and very complicated issue.
In general, the transition to PPG is designed to provide States
more flexibility in the use of funds while instituting a system of
improved accountability based on performance. NASADAD has been working
with SAMHSA on this transition over the past few years.
As part of the transition, the Children's Health Act of 2000
required the Secretary of Health and Human Services (HHS) to submit a
plan to Congress on issues pertaining to this complicated process. In
particular, Public Law directed the report to include
(1) a description of the flexibility States need;
(2) performance measures that would be used for accountability;
(3) the definitions for the data elements to be used under the
plan;
(4) obstacles to implementation of the plan;
(5) resources needed to implement the performance partnerships; and
(6) an implementation strategy complete with any recommended
legislation.
Federal Funding Needed for PPG Implementation--Specific Need for Data
Management & Infrastructure Development
While I understand that this panel is not the Appropriations
Committee, I must touch on one aspect of the report that is due to
Congress--the resources needed for the PPG. Data infrastructure
development and management are the basic ingredients to success in our
efforts to plan for, and implement, the PPG. Although stakeholders have
unanimously agreed that States will require fiscal and technical
assistance in order to help significantly adjust, or in some cases,
overhaul, their data collection systems, the development and refinement
of performance measures has shown how much work needs to be done.
Resources are needed to help States build the systems that will
collect, track, refine, manage, analyze and disseminate accurate data
in accordance with the anticipated new requirements in the PPG. Funds
are needed to help States evaluate current data collection and
reporting capabilities against the many new data requirements.
Resources are also needed to help address the costs that States are
facing in order to reach compliance with certain provisions in the
Health Insurance Portability and Accountability Act (HIPAA).
The implementation of the PPG is predicated on the current system
of providing adequate and baseline funding levels to each State for
substance abuse prevention and treatment services.
Assessment of State Reporting Capabilities--As Called for in Public Law
106-310
Part C, Subpart I, Section 1971 (a) of Public Law 106-310 (SAMHSA
Reauthorization) notes that ``The Secretary will establish criteria for
determining whether a State has a fundamental basis for the collection,
analysis, and reporting of data.'' With this in mind, NASADAD strongly
believes that SAMHSA must work to help States determine their own
unique data reporting capabilities related to the new and expanded
requirements generated by the PPG.
Need for More Localized Data
NASADAD also recommends work to re-establish an initiative
consistent with the goals of the State Treatment Needs Assessment
Program (STNAP). Similarly, we also support initiatives that will help
assess the need for prevention services at the local level. While the
NHSDA may provide a useful national overview, we recommend working to
identify a mutually acceptable system of measurement that would capture
relevant data at the sub-State level. This type of data collection is
critical in order to have better access to ``real-time'' information
that describes unmet need in our States and communities. In addition,
this data is also needed to accurately and efficiently measure our
progress in reaching the President's 2- and 5-year goals to reduce drug
use as we seek to close the treatment gap.
A Concern With Timing of PPG Implementation
NASADAD is extremely concerned with the timing of PPG
implementation. Every effort should be made to begin to implement a
workable system, within a reasonable timeframe, that is clear and
efficient for the purposes of helping States with their substance abuse
services delivery system and of course, improving the lives of the
clients they serve. As a result, many questions will undoubtedly remain
regarding performance measures, data elements, methodologies and other
details of the PPG.
In the Federal Register Notice (FRN) related to the PPG transition,
a section on performance measures noted that ``all States will begin
submitting some of the prevention information for the fiscal year 2005
application, and all States will be able to submit all the data by
fiscal year 2006 applications.'' Further, in its discussion of the
treatment performance measures, the FRN says, ``[S]ome States will be
able to report on the performance data in time for the fiscal year 2005
application. Other States will be asked for a plan of implementation on
the collection and reporting on the data.'' NASADAD remains very
concerned with this portion of the FRN.
NASADAD is also concerned with language included in the House
Appropriations Committee Report accompanying the bill providing funding
for the Departments of Labor, Health and Human Services (HHS),
Education and Related Agencies (Report number 108-188). The Report
notes:
It is the Committee's expectation that SAMHSA will begin
integrating performance measurement into the Substance Abuse Prevention
and Treatment Block Grant in Fiscal Year 2004 as States prepare to move
to the Performance Partnership Grant. As data become available on the
development of performance guidelines and of the actual performance of
these programs, the Committee strongly urges SAMHSA to provide Congress
periodic updates.
NASADAD recommends that any changes in the Block Grant
application, and thus the reporting and implementation of performance
measures, only begin after the following move forward:
An assessment by the Secretary of HHS of States' readiness
to report PPG data,
The allocation of new and additional resources to assist
with data infrastructure and other administrative costs, and
A process whereby any legislation passed by Congress, and
signed by the President, reflects an agreement that incorporates the
input of Governors, NASADAD, and other stakeholders.
other issues related to reauthorization
Policies Relating to Co-occurring Mental Health and Substance Use
Disorders
A top priority for NASADAD relates to policies that impact the
provision of services to those persons with co-occurring substance use
and mental health disorders. NASADAD would like to note that any policy
recommendations made should flow from, and be consistent with, the
collaborative work done by NASADAD and the National Association of
State Mental Health Program Directors (NASMHPD). This includes the
National Dialogue on Co-occurring Mental Health and Substance Abuse
Disorders and subsequent findings by the NASADAD--NASMHPD Joint Task
Force on Co-occurring Disorders. This work, made possible in part due
to the generous support of SAMHSA, was formally adopted by the Board of
Directors of both NASADAD and NASMHPD, and presented to the membership
of both organizations during a combined meeting in Reno, Nevada in
2000.
As this Committee considers reauthorization issues, NASADAD would
offer the following considerations as discussions move forward:
The Promotion of and Use of Common and Consistent
Language: We believe it is vital to work together to promote the use of
common and consistent language as policies regarding services to
populations with co-occurring mental health and substance use disorders
are examined. For example, we recommend that more work be done to
advance a consistent definition and understanding of the term
``integrated treatment'' by using the NASADAD--NASMHPD Joint Conceptual
Framework Documents.
More Research and Data Presentation: We would like to work
with SAMHSA to generate better data regarding those with co-occurring
mental health and substance use disorders. Policy recommendations
should then flow from subsequent findings contained in the research
using appropriate and consistent terms and definitions. Policy
recommendations, in our view, should not precede the research. In
examining the larger picture, we would like to work with SAMHSA to
develop a concrete plan and vision for data issues. As the lead Federal
Agency for substance abuse and mental health services, for example,
SAMHSA could help encourage other Federal agencies that fund addiction
services to work with States and others in the development of a
coordinated data plan.
Workforce: We can not improve services to those with
mental health and substance use disorders without an adequate number of
appropriately trained, licensed, experienced and fairly compensated
professionals. We recommend the establishment of workforce initiatives
and a National Workforce Development Office within SAMHSA.
Synar Provision
Another issue we believe requires attention is the Synar provision.
The goal of Synar is to reduce tobacco sales to minors. NASADAD members
and Governors are strongly committed to reducing youth smoking and
restricting underage access to tobacco. In turn, States have committed
substantial resources and time for the enforcement of the Synar
provision. The Synar provision required States to enact laws
prohibiting tobacco sales to minors and to achieve an 80 percent
compliance rate among tobacco vendors. HHS issued regulations for Synar
enforcement that established baseline annual target rates for each
State. The penalty for noncompliance with Synar is a severe 40 percent
cut to the State's Substance Abuse and Prevention Treatment Block
Grant.
We agree with the National Governors Association (NGA) in noting
that Congress has taken an important first step by inserting language
into the fiscal year 2000, 2001, 2002 and 2003 appropriations bills
that would save States that commit substantial resources to the goals
of Synar from suffering severe penalties to their Block Grant. NASADAD
strongly supports NGA in calling for substantial, long-term changes in
the administration of the law and the statute itself. These changes are
needed in order to ensure that States and the Federal Government work
together to meet their common goal of reducing tobacco sales to minors
without penalizing populations in need of substance abuse prevention
and treatment services. NASADAD also strongly supports NGA's position
that calls for the establishment of a Synar enforcement structure that
does not threaten, interrupt or eliminate critical substance abuse
prevention and treatment services.
Inclusion of States in SAMHSA Grants
As you may know, each State crafts a State-level plan for addiction
services. These plans are based on State-level studies that assess
targeted prevention and treatment service needs. States are in the best
position to determine how to effectively utilize and distribute
resources. With this in mind, we would ask that discussions move
forward during the reauthorization process that examine SAMHSA funded
programs that do not incorporate State systems during the planning and
implementation stages. Grants that are developed without examining
their impact on State systems can create situations where entities
eventually turn to States for resources when the grant expires--without
giving the State agencies adequate time to plan to consider the support
of such requests. In turn, States often have a difficult time providing
funds to these programs because of the lack of communication,
coordination and planning.
NASADAD believes that State systems must be directly considered and
involved in any SAMHSA grant program to ensure that resources are
distributed in coordination with State planning processes. We believe,
for example, that States should be eligible to apply for all Targeted
Capacity Expansion (TCE) program grants. In sum, we believe State
involvement will prevent the creation of programs that become
redundant, inefficient, disconnected and at times, discontinued.
Programs Within the Center for Substance Abuse Prevention (CSAP)
The State Incentive Grant (SIG) program has proven to be a
successful program. The competitive grants (there have been 41 funded
to date) flow directly through the Governors' Offices, through various
divisions of State government, and ultimately down to the level of
grassroots coalitions. It is an effective mechanism designed to
``bridge'' formerly disparate government entities (e.g., the State AOD
agency, the criminal justice agency, the child welfare agency, the
education agency) who share the common vision of substance abuse
prevention.
The Decision Support System--launched 3 years ago--has already
proven to be a remarkable, cutting-edge tool that makes use of the
World Wide Web platform. This user-friendly interactive system enables
the individual to access not only the registry of effective model
programs (described below), but also offers general technical
assistance, information on State-supported prevention systems (via
State ``portals''), and assessment tools relevant to the measurement of
risk and protective factors within a target population. In an era of
increased accountability and performance-based reporting, such an
interactive Web-based tool becomes invaluable to the substance abuse
prevention community.
The dissemination of model programs is proving to be a useful
mechanism in assisting States and communities in replicating and
adopting evidence-based practices that are specifically tailored to
various demographic target populations. The database created by CSAP,
the National Registry of Effective Programs, is the primary national
repository for scientifically validated drug, tobacco and alcohol
prevention programs.
CSAP and its contractors have developed a programmatic portfolio of
valuable prevention-based programs aimed at targeting youth entering
life ``transitions'' (e.g., the beginning of adolescence, entering
college). Also, comprehensive work-based programs target the nearly
three-fourths of illicit drug users who are in the workforce. States
have come to rely on CSAP's identification and dissemination of
evidence-based scientifically validated prevention programs. Progress
achieved to date through this programmatic portfolio should continue.
Development and training of an effective prevention workforce is
particularly vital as the Nation's economy has taken a downturn and
many States are under increasingly stricter financial constraints. To
date, many States and Territories have relied heavily on the successful
CSAP-funded Centers for the Application of Prevention Technology
(CAPTs), of which there are six (6) regional centers. Training,
technical assistance with workforce development, and access to state-
of-the-art model prevention programs comprise the CAPTs' aggregate
portfolio.
Conclusion
Thank you very much for listening to my testimony. Again, I look
forward to working with the Committee, SAMHSA, NGA and others as we the
reauthorization process moves forward. I would be happy to address any
questions the committee may have.
Senator DeWine. Director Knisley?
Ms. Knisley. Mr. Chairman, Senator Reed, and Senator
Murray, thank you for this opportunity to provide testimony to
you this morning about the Substance Abuse and Mental Health
Services Administration reauthorization.
I am Martha Knisley, and I am the first director of the
Department of Mental Health for the District of Columbia and,
more important, I am a southern Ohioan.
Senator DeWine. Noted; very important.
Ms. Knisley. I am speaking today on behalf of the National
Association of State Mental Health Program Directors, the
association that represents the public mental health
authorities in the 50 States, the District of Columbia, and the
Territories.
We are particularly pleased to be before you today in this
first hearing of the Senate Subcommittee on Substance Abuse and
Mental Health Services. The special focus of the subcommittee
reflects the critical need for improved access to mental health
services at a time when an overwhelming majority of Americans,
both adults and children, with mental disorders and emotional
problems do not receive appropriate treatment.
We are hopeful that your work, combined with the much-
anticipated release of the President's New Freedom Commission
on Mental Health's final report, will strengthen our Nation's
commitment to ensuring access to treatment and promoting
recovery and full participation. We must recognize that we have
a lot of work to do, both to vast improve and to save lives.
I am also very pleased to present this testimony on behalf
of the Campaign for Mental Health Reform. As I am sure you
understand, the President's Commission, even before its report
has been released, has galvanized the mental health community,
including consumers, providers, family members, advocates, and
administrators. There could not be a more appropriate or
exciting time to reauthorize SAMHSA and its programs, since we
expect that the President will be looking to SAMHSA to
coordinate and move forward an action plan stemming from the
Commission's recommendations.
Charles Curie, SAMHSA's administrator, has expressed
support for a strong Federal role in shaping mental health. We
value his leadership. I have known and worked with him for over
25 years, and we look forward to continuing to work in
partnership with Mr. Curie and his team. And we are
tremendously excited that Kathryn Power, the director of Rhode
Island's Department of Mental Health, will soon be taking the
helm at CMHS.
However, SAMHSA will succeed in addressing the priorities
and meeting the goals the administrator has laid out only if
the have the empowerment of the agency to do so, and it is
important that this come from Congress. Too often in the past,
SAMHSA has not been granted the authority or the funding to
achieve systems reform even when there was consensus in the
field about that reform.
We expect the focus of the President's Commission's report
will be on the fragmentation found in the mental health system.
This system, where consumers and family members are still
forced to navigate multiple unconnected service systems,
including but not limited to housing, substance abuse,
employment, education, criminal justice, Medicaid, child
welfare, mental health--and I could go on--SAMHSA must play a
vital role, a pivotal role, in assuring that all of these
service systems are brought together into a single system of
care.
This is particularly acute with respect to children. To
address it, we recommend that through legislation, Congress
establish an interagency body on children's mental health
services across the Department of Health and Human Services and
that this body report to Congress on those Federal laws and
regulations that impeded full realization of the legislation's
objectives.
For example, at Mayor Williams' request, the District,
through legislation when it created our new Department of
Mental Health, created an interagency body to work on
children's issues across all of these systems. We have had
positive outcomes in just 2 years by doing this.
For example, sine last November, we have diverted 230 out
of 260 children referred for out-of-District institutional care
because of our coming to work together under this interagency
group.
SAMHSA also needs greater authority to promote cross-system
collaboration and integration in a number of other areas, but I
will mention just two this morning.
The first is in the tragic over-representation of people
with mental illness in the criminal justice system. We applaud
you, Senator DeWine, in particular for your leadership on this
issue and for introducing legislation to promote collaboration
between State and local mental health and criminal justice
agencies.
Second, we commend SAMHSA for identifying as a priority the
improvement of services to the approximately 10 million
Americans with co-occurring mental abuse and substance about
disorders. Evidence-based treatments for these conditions are
remarkably effective. Such treatments involve having an
integrated approach--not a parallel or a sequential approach--
to treatment, and if we do it in parallel fashion or sequential
fashion, it will be more expensive, and we will have poor
outcomes. But even today at the Federal level, mental health
block grants are kept separate, so these funding streams must
be separated out at the local level.
Here in the District, Mayor Williams, the director of the
Department of Health, and myself have just signed a charter
agreement where we assure that our policies, funding, program
access and all aspects of service delivery are combined into a
single, focused approach for persons with dual disorders. Yet
we are forced to work around the separateness that still exists
at the Federal level. We urge you to modify the legislation to
promote the provision of integrated services for persons with
co-occurring disorders.
Eliminating barriers to financing integrated treatment will
not only improve treatment outcomes but will reduce the most
common adverse consequences they face, such as criminal justice
involvement, unemployment, and homelessness. We hope that
SAMHSA is granted both the authority and the funding also to
provide services in permanent supported housing for individuals
to end chronic homelessness.
We hope that Congress will give attention to the imminent
conversion of the Mental Health Block Grant Program to
Performance Partnership Grant. Measuring the performance and
effectiveness of mental health programs and services can result
in more sophisticated planning at the State level. But our
block grant today only comprises 2 percent, and as a matter of
fact, in the District, only one percent of our overall funding.
The Performance Grants will be looking at our entire
program, and we must be assured that we will have the resources
to fully develop the data necessary for this national picture.
Finally, I want to say just one word about the shifting of
SAMHSA's research functions to the National Institute of Mental
Health. We support SAMHSA's efforts to streamline and eliminate
duplication in Federal agencies, but we emphasize that services
research must be continued and enhanced, and we will be looking
closely to see that this occurs during this shift.
Again, thank you for this opportunity to speak with you
this morning. I am happy to answer any questions that you may
have.
Senator DeWine. Thank you very much.
[The prepared statement of Ms. Knisley follows:]
Prepared Statement of Martha B. Knisley
Mr. Chairman, Senator Kennedy, and Members of the Subcommittee,
thank you for the opportunity to provide testimony to you this morning
about the Substance Abuse and Mental Health Services Administration
(SAMHSA). My name is Martha Knisley, and I am the Director of the
Department of Mental Health in the District of Columbia. I have worked
in public mental health, substance abuse and developmentally
disabilities for over 35 years and have served as Director of Mental
Health in Ohio and Deputy Secretary for Mental Health in Pennsylvania.
I am speaking today on behalf of the National Association of State
Mental Health Program Directors, the association that represents the
public mental health authorities in the 50 States, the District of
Columbia, and the Territories.
I am particularly pleased to appear before you today in this first
hearing of the Senate Subcommittee on Substance Abuse and Mental Health
Services. The special focus of this Subcommittee reflects the critical
need for improved access to mental health services at a time when an
overwhelming majority of Americans with mental disorders do not receive
appropriate treatment. This is particularly discouraging given that
great strides have been made through medical research demonstrating the
effectiveness of a range of such treatments for these serious
conditions. We are hopeful that your work, combined with the much-
anticipated release of the President's New Freedom Commission on Mental
Health's final report, will strengthen our Nation's commitment to
ensuring access to treatment and promoting recovery and full community
participation. Thank you for understanding the importance of this issue
and recognizing the potential to vast improve and save lives.
I am also very pleased to present this testimony on behalf of the
Campaign for Mental Health Reform. As I am sure you understand, the
President's Commission--even before its report has been released--has
galvanized the mental health community, which includes consumers,
family members, providers, administrators, and advocates. This
community is represented by numerous organizations with diverse
interests and different perspectives. Despite these differences, they
are joining together to collaborate in an unprecedented fashion to
launch the Campaign for Mental Health Reform. Building on the work of
the President's Commission, the Campaign will develop and promote
Federal policy initiatives based on shared values and principles and
will strive to advance mental health as a national priority.
There could not be a more appropriate or exciting time to
reauthorize SAMHSA and its programs, since we can expect that the
President will be turning to this agency to formulate and coordinate an
action plan stemming from the Commission's recommendations. Therefore,
nothing could be more important than ensuring that SAMHSA has the
authority and resources to get this job done.
Charles Curie, SAMHSA's Administrator, has expressed support for a
strong Federal role in shaping mental health policy and in supporting
efforts to provide mental health services in appropriate, community-
based settings efficiently and effectively. We value the
Administrator's leadership and look forward to continuing to work in
partnership with Mr. Curie and his team. Indeed, we are indebted to
Gail Hutchings who for the past year has served with distinction as the
Center for Mental Health Services' Acting Director, and we are
tremendously excited that Kathryn Power, the Director of Rhode Island's
Department of Mental Health, will soon be taking the helm of CMHS.
However, SAMHSA will succeed in addressing the priorities and
meeting the goals the Administrator has laid out only if Congress
empowers the agency to do so. Too often in the past, SAMHSA has not
been granted the authority or the funding to achieve systems reform,
even where there is a consensus in the field about the obstacles and
remedies.
We expect that the focus of the President's Commission's report
will be on the fragmentation found in the mental health system: that
consumers and family members seeking appropriate services are forced to
navigate multiple unconnected service systems, including, but not
limited to, housing, substance abuse, employment, education, criminal
justice, Medicaid, child welfare, and mental health. SAMHSA could and
should play a the pivotal role in aligning these programs to more
effectively and efficiently serve adults and children with mental
health disorders and in leading an initiative for collaboration across
various Federal Agencies so as to create greater unity in mission,
objectives, and oversight in Federal programs.
This need is particularly acute with respect to children. To
address it, we recommend that, through legislation, Congress establish
an interagency body on children's mental health across the Departments
of Health and Human Services, Education, and Justice that would foster
systems coordination, collaboration, and joint financing across all
relevant Federal programs. Lead-agency responsibility for this function
would be vested in SAMHSA, which would oversee the design and
implementation of a comprehensive, interagency approach to children's
mental health and report to Congress on those Federal laws and
regulations that impede full realization of the legislation's
objectives. At Mayor Williams' request, the District through
legislation created such an interagency body when we established the
new Department of Mental Health 2 years ago; this has led to many
positive outcomes. For example, since November of 2002 we have diverted
over 230 children and youth from District institutional care as a
result of this action. Building a system of care for children, youth
and their families is our highest priority. We believe strongly that
prevention, early intervention and community treatment work when we
commit resources and work together with families and our partners in
education, child welfare, juvenile justice and other systems.
SAMHSA needs greater authority to promote cross-system
collaboration and integration in others areas, but two deserve
particular attention.
First, we are encouraged that SAMHSA recognizes the tragic over-
representation of people with mental illness in the criminal justice
system. According to the U.S. Department of Justice, about 16 percent
of the Nation's jail and prison population have a mental illness.
Incarceration is far costlier than treatment and has significant
negative consequences, not only for people with mental illnesses
languishing unnecessarily in jail, but for the criminal justice system
as well. We applaud Senator DeWine in particular for his leadership on
this issue and for introducing legislation to promote collaboration
between State and local mental health and criminal justice agencies. As
provided in the legislation, the Department of Justice will need to
work with the Department of Health and Human Services to administer the
program; therefore, we urge that SAMHSA be given the resources
necessary to play that role.
Second, we commend SAMHSA for identifying as a priority the
improvement of services to the approximately 10 million Americans with
co-occurring mental illness and substance abuse disorders. Evidence-
based treatments for these conditions are remarkably effective. Such
treatments involve integrated approaches that address both the mental
illness and the substance abuse problem concurrently. Federal programs
that isolate funding streams for mental health and substance abuse into
separate ``silos'' result in ``parallel'' or ``sequential'' treatment--
expensive approaches with poor outcomes for individuals with co-
occurring disorders. Unfortunately, statutory language associated with
the substance abuse and mental health block grants sends the message
that these funding streams must be kept separate and poses an obstacle
to States and localities that want to furnish the treatment that is
most effective.
In the District of Columbia, Mayor Williams, Jim Buford, the
Director of the Department of Health, where substance abuse programs
reside, and I recently signed a Charter Agreement to assure that our
policies, funding, program access and all aspects of service delivery
are combined to provide a single and focused approach for treating
persons with dual disorders. Yet we are forced to work around the
separateness that still exists at the Federal level. We urge Congress
to modify the legislation and to promote the provision of integrated
treatment for individuals with co-occurring disorders.
Eliminating barriers to financing integrated treatment in the two
block grants will not only improve the treatment outcomes of
individuals with co-occurring disorders, but also reduce the most
common adverse consequences they face, such as criminal justice
involvement, unemployment, and homelessness. In the District, we
estimate that 42 percent of adults who are homeless have a co-occurring
disorder. Therefore, we are encouraged that, in addition to improving
integrated treatment services, SAMSHA intends to play a key role in the
Administration's initiative to end chronic homelessness. At the State
and local level, we must work long and hard to help persons who have
been streetbound regain control over their lives and maintain a
permanent place to reside. We hope that SAMHSA is granted both the
authority and the funding to provide services in permanent supported
housing for individuals exiting chronic homelessness.
In addition to invigorating SAMHSA's successful programs such as
Projects for Assistance in Transition from Homelessness (PATH) and the
Comprehensive Community Mental Health Services for Children and their
Families Program, we hope that Congress will give attention to the
imminent conversion of the mental health block grant to a Performance
Partnership Grant. Measuring performance and effectiveness of mental
health programs and services results in more sophisticated planning at
the State level, enhanced accountability at all levels of government,
and, in short, more effective use of scarce resources. But committing
to this agenda in a meaningful way, such that performance data can be
measured across States and aggregated to present a national picture--a
key goal of the Performance Partnership--will also be very expensive to
providers, States, and SAMHSA. Most States already collect and analyze
significant amounts of data to support their own internal planning and
quality improvement activities. Under the Performance Partnership we
would be required to meet national goals for measuring performance and
effectiveness, but this will require uniform and standardized data
collection, analysis, and reporting. Moreover, these new requirements
will apply to States' entire mental health systems--not just the block
grant that is the focus of the performance partnership--even though the
block grant represents, on average, less than 2 percent of State mental
health agency operating budgets. In the District, the Block Grant
represents less than 1 percent of our budget. Therefore, to the extent
Congress wishes mental health programs to generate standardized data
such that policymakers at the Federal level can better assess the
effectiveness of these programs--a goal we enthusiastically support--we
urge that Congress provide the funding to make this happen.
In addition, we want to express our support for SAMHSA's leadership
role in reducing and ultimately eliminating the use of restraints and
seclusion among individuals with mental illnesses. SAMHSA has
significant expertise and a proven track record in spearheading
successful initiatives designed to achieve this goal.
And finally, we want to say a word about the shifting of SAMHSA's
research functions to the National Institute for Mental Health (NIMH).
We support SAMHSA's efforts to streamline and eliminate duplication in
Federal agencies, but emphasize that services research must be
continued and enhanced. This research builds on the significant
investments that NIMH traditionally has made in understanding the
science of mental illness, and ensures the cost-effectiveness of those
investments. More importantly, services research is a critical bridge
across the chasm between what we know about mental illness and what we
do in providing services; the implications of reduced attention to this
research are enormous. We are confident that this Subcommittee agrees
that it must ensure that critical support for services research is
maintained and expanded.
Again, thank you for the opportunity to speak with you this
morning. I am happy to respond to any questions you may have.
Senator DeWine. Ms. Walker.
Ms. Walker. Chairman DeWine, Senator Reed, and Senator
Murray, I am Gloria Walker of Cincinnati, OH. On behalf of NAMI
Ohio and NAMI National, I want to thank you and Senators Gregg
and Kennedy for establishing the first standing subcommittee in
the history of the Congress dedicated to addressing services
for individuals with mental illness and addictive disorders.
This subcommittee is an enormous leap forward in addressing
the historic stigma and discrimination that has left the public
mental health and substance abuse treatment systems fragmented,
underfunded, and overburdened.
I am here today not just as a member and director of NAMI
National and NAMI Ohio, but also as the mother of a son who has
struggled with severe mental illness for nearly 20 years.
I am strongly encouraged by the advances that have been
made in treatment for illness over the past decade. This
scientific advance is heralding new opportunities for recovery
and a full life for my son. He is fortunate to be living in
Ohio, where we have perhaps the Nation's best public sector
system under the leadership of our mental health commissioner,
Dr. Mike Hogan, and Governor Bob Taft.
As you know, we in Ohio have made enormous progress in
making sure that services in the community are reflective of
the advances that have been made in clinical treatment and
service delivery. Unfortunately, Ohio is the exception and not
the rule when it comes to mental illness treatment services
delivered in public sector programs. In fact there is strong
evidence that the public health system in our country is in
collapse in many States. This crisis is worsening in many parts
of the country as States face a deteriorating budget situation.
The result is that children and adults living with severe
mental illness are increasingly over-represented in the chronic
homeless population and in local jails and prisons.
The failure of this system is also reflected in our
Nation's high suicide rate. This year, NAMI completed its most
comprehensive survey of our consumer and family membership,
with 3,400 respondents. The findings are alarming.
Nearly half the consumer respondents reflected in the
survey had been hospitalized within the past 12 months, and 40
percent needed emergency services. Fewer than one-third
received evidence-based, recovery-oriented services such as
assertive community treatment programs, supported employment
services, and substance abuse treatment. More troubling is that
the lack of appropriate treatment translated into extensive
involvement with the criminal justice system. Forty-three
percent of the consumers in the NAMI survey had been arrested
or detailed by police.
NAMI recognizes that SAMHSA cannot fix every problem
confronting State mental health authorities across the country.
However, SAMHSA can and should assist State and local mental
health authorities to more effectively use their limited
resources and to help States ensure that they are making the
right investments.
NAMI would like to offer the following recommendations with
respect to SAMHSA reauthorization legislation that this
subcommittee will soon consider.
SAMHSA needs to provide stronger leadership in bridging the
divide between science and practice to ensure wider replication
of evidence-based practice.
SAMHSA needs to provide stronger leadership in improving
the data infrastructure capacity of the public mental health
system.
SAMHSA should be encouraged to continue its mission to make
treatment for co-occurring mental illness and substance abuse
disorders a priority. SAMHSA is placing a high priority on
addressing the needs of the estimated 10 million Americans who
have co-occurring mental illness and substance abuse disorders.
SAMHSA should play a stronger role in helping to meet
President Bush's goal of ending chronic homelessness over the
next decade. NAMI supports President Bush's Samaritan
Initiative, and we urge you to build on this effort by creating
a new flexible funding stream to finance services in permanent
supported housing.
SAMHSA should expand its efforts to address the growing and
disturbing trend of criminalization of mental illness
experienced by adults in jails and prisons, and adolescents in
juvenile justice programs.
Chairman DeWine, NAMI is extremely grateful for the
leadership that you have provided in Congress in bringing
attention to this enormous and growing problem.
Finally, SAMHSA should continue its efforts to address the
absence of a coherent service system for children and
adolescents with serious mental illness. This morning, your
colleagues on the Governmental Affairs Committee are hearing
testimony from families with children with mental illness who
have been forced to relinquish custody in order to access
services for their children. This is the most glaring, extreme
evidence of the near absence of a system of services for
children and adolescents in our country. This is a complex
issue where accountability is spread across multiple systems
including Medicaid, child welfare, foster care, juvenile
justice, and mental health. Clearly, something must be done to
improve collaboration, systems coordination, and blended
funding of services for children with mental illness across all
relevant programs and systems.
SAMHSA has an important role to play in fostering
coordination of home and community-based services for children
with mental illness and their families.
Mr. Chairman, on behalf of the more than 1,000 NAMI
organizations across the country, thank you for this
opportunity to offer our views on this important issue.
[The prepared statement of Ms. Walker follows:]
Prepared Statement of Gloria Walker
Chairman DeWine, Senator Kennedy and Members of the Subcommittee, I
am Gloria Walker of Cincinnati, Ohio. Since 2000, I have served on the
Board of Directors of the National Alliance for the Mentally Ill
(NAMI). I am also a Past President of NAMI Ohio, having served in that
capacity from 1998 until 2000. I am also the mother of a son who has
struggled with mental illness for nearly 20 years. It is from these
perspectives--a leader in the NAMI movement and as a family member--
that I offer the following views on the future of SAMHSA and the need
to improve the Federal Government's response to the growing crisis in
our public mental health system.
Who is NAMI?
NAMI is a nonprofit, grassroots, self-help, support and advocacy
organization of consumers, families, and friends of people with severe
mental illnesses, such as schizophrenia, schizoaffective disorder,
bipolar disorder, major depressive disorder, obsessive-compulsive
disorder, panic and other severe anxiety disorders, autism and
pervasive developmental disorders, attention deficit/hyperactivity
disorder, and other severe and persistent mental illnesses that affect
the brain.
Founded in 1979, NAMI today works to achieve equitable services and
treatment for more than 15 million Americans living with severe mental
illnesses and their families. Hundreds of thousands of volunteers
participate in more than 1,000 local affiliates and 50 State
organizations to provide education and support, combat stigma, support
increased funding for research, and advocate for adequate health
insurance, housing, rehabilitation, and jobs for people with mental
illnesses and their families. Local affiliates and State organizations
identify and work on issues most important to their community and
State. Individual membership and the extraordinary work of hundreds of
thousands of volunteer leaders is the lifeblood of NAMI's local
affiliates and State organizations.
I am pleased today to submit the following testimony on behalf of
the National Alliance for the Mentally Ill (NAMI) on legislation to
reauthorize the Substance Abuse and Mental Health Services
Administration (SAMHSA).
Public Mental Health System In Crisis
Mr. Chairman, as you know in a matter of days President Bush's
Commission on Mental Health (chaired by our own Mike Hogan of Ohio)
will be releasing its final report. We expect this report will document
what too many NAMI members know from personal experience--that the
public mental health treatment and support system in most States is in
serious disrepair. In fact, as the Commission noted in its Interim
Report last fall, this ``system'' is in fact not a coherent system, but
rather a fragmented and underfunded series of programs crossing
multiple layers of government with little accountability and
coordination. I can tell you from personal experience that this
confusing system overwhelms consumers and families with conflicting
eligibility rules and reliance on service models that are inconsistent
with the enormous scientific advances that have been made in recent
years with respect to recovery-oriented interventions for severe mental
illness.
The result of this system in collapse is that children and adults
living with severe mental illness are increasingly over-represented in
the chronic homeless population and in local jails and prisons. The
failure of this system is also reflected in our Nation's alarmingly
high suicide rate. This year NAMI completed its most comprehensive
survey of our consumer and family membership--3,400 respondents. The
findings are alarming.
Nearly half of the consumer respondents reflected in the survey had
been hospitalized within the past 12 months and 40 percent needed
emergency services. Fewer than one-third received evidence-based,
recovery-oriented services such as assertive community treatment
programs, supported employment services, and substance abuse treatment.
More troubling is that the lack of appropriate treatment translated
into extensive involvement with the criminal justice system--43 percent
of the consumers in the NAMI survey have been arrested or detained by
police.
SAMHSA's Response to the Growing Crisis in the Public Mental Health
System
Given SAMHSA's limited resources ($3.2 billion in a system
estimated to consume more than $44 billion), it is unrealistic (and
probably unwise) to expect the agency to assume responsibility for
complete reform of the complicated and fragmented system that consumers
and families must navigate. At the same time, SAMHSA can (and should)
play a leadership role in assisting States and localities in
modernizing and reforming the way mental illness treatment and supports
are delivered. Reauthorization legislation therefore affords an
important opportunity for Congress to sharpen the agency's mission to
assist State and local mental health authorities in this effort.
NAMI is pleased that the Bush Administration has appointed three
leaders with experience in running State mental health authorities to
manage SAMHSA and the Center for Mental Health Services (CMHS):
Administrator Charles Curie of Pennsylvania, Deputy Administrator James
Stone of New York and CMHS Director Kathryn Power of Rhode Island. Each
brings vast experience in managing and reforming services and working
with NAMI organizations at the State and local level.
NAMI Recommendations for SAMHSA Reauthorization
1. SAMHSA needs to provide stronger leadership in bridging the
divide between science and practice to ensure wider replication of
evidence-based practice.
Over the past 5 years, SAMHSA has made enormous progress in
transforming its programs to create a stronger grounding in science and
enhanced emphasis on replication of evidence-based practice. NAMI
supports this effort to refine and sharpen SAMHSA's mission to ensure
that it is firmly grounded in furthering investment in clinical
treatment and that service models are informed by research and
recovery-oriented outcomes. This shift is beginning to take place as
part of SAMHSA's Programs of Regional and National Significance (PRNS)
which funds community action grants and targeted capacity expansion in
priority areas such as assertive community treatment, jail diversion,
suicide prevention and treatment for co-occurring disorders.
NAMI is also supportive of efforts by SAMHSA to develop a new level
of cooperation with colleague agencies at the National Institutes of
Health (NIH). It is critically important for SAMHSA and NIH to develop
a more workable partnership with respect to services research and
services demonstration studies that assess how best to deliver clinical
services in real world settings. This is especially the case given the
challenges particular to the real world settings in which children and
adults are increasingly receiving services: homeless shelters,
emergency rooms, jails, juvenile justice facilities, schools and
primary care. Both agencies have strengths that need to be effectively
coordinated to develop a stronger research base on service delivery and
technical assistance capacity for pushing State and local authorities
and front-line providers to invest in evidence-based practice.
NAMI therefore recommends that this Subcommittee redirect SAMHSA to
its core mission of assisting State and local mental health agencies in
bridging the gap between science and practice, with particular focus on
replication of evidence-base practices grounded in recovery-oriented
services for children and adults living with severe mental illnesses.
2. SAMHSA needs to provide stronger leadership in improving the
data infrastructure capacity of the public mental health system.
In 2000, Congress directed SAMHSA to convert its separate substance
abuse and mental health block grant programs to ``Performance
Partnership Grants'' (PPGs). The objective was to reform these block
grant programs to promote greater emphasis on evidence that measure the
performance of States in meeting specific goals, and away from
expenditure reports tracking where and how funds are spent. NAMI
applauded this effort as part of a larger strategy designed to push
States to begin developing better data systems that actually measure
progress in meeting outcomes related to treatment, recovery and
provider performance.
While SAMHSA has met the goal of converting the block grants to
PPGs, NAMI believes that further steps need to be taken to finally put
in place effective data collection and dissemination systems. NAMI
believes that such a data infrastructure should be able to measure not
only performance outcomes achieved with funds allocated through SAMHSA,
but all State and local resources as well, whether or not those dollars
directly flow through the State mental health authority or other
sources (e.g. Medicaid). As was the case with conversion to the PPG
model, such data systems should be able to facilitate assessment of
progress toward specific outcome measures and an unduplicated count of
who is being served.
NAMI has long been frustrated with the lack of a coherent system of
data collection for public mental health spending. The inability to
compare and measure the performance of State public mental health
systems has been a major impediment to progress in seeking adequate
resources to fund public sector programs. After years of frustration,
NAMI has acted on its own to establish TRIAD--the Treatment, Recovery,
Advocacy and Information Database. This is our own effort to develop a
set of measures to assess the performance of States tied to recovery
for consumers and their family members. As excited as we are about the
data being generated by TRIAD, we are nonetheless discouraged that the
inconsistencies of data collection and dissemination systems across the
States and SAMHSA still prevents meaningful comparisons across the
States.
3. SAMHSA should be encouraged to continue its mission to make
treatment for co-occurring mental illness and substance abuse disorders
a priority.
NAMI is especially pleased that SAMHSA Administrator Curie has
placed such a high priority on addressing the needs of the estimated 10
million Americans who have co-occurring mental illness and substance
abuse disorders. SAMHSA's November 2002 report to Congress (mandated by
this Committee in 2000) is an important step forward in compiling
existing data on the extent of the problem and current research on
effective clinical interventions. NAMI agrees that there should be ``no
wrong door'' for entering treatment for individuals with co-occurring
disorders.
NAMI also agrees that the existing research literature clearly
demonstrates that neither mental illness, nor chemical dependency
treatment, can be effective unless both are provided in an integrated
fashion through interdisciplinary coordination. However, despite this
report we are still seeing too little investment from the separate
mental health and substance abuse systems in integrated mental health
and substance abuse treatment. NAMI believes that accounting and
regulatory burdens are still serving as a barrier to fostering
development of integrated treatment by State and local agencies. NAMI
would therefore urge this Subcommittee to consider statutory language
to make it clear that States may utilize funds from the Mental Health
and Substance Abuse PPGs to provide integrated treatment to individuals
with co-occurring disorders.
4. SAMHSA should play a stronger role in helping to meet President
Bush's goal of ending chronic homelessness over the next decade.
As you know, President Bush (through the leadership of the White
House Interagency Council on the Homeless) has put forward his
``Samaritan Initiative'' to end chronic homelessness over the next
decade. In addition, Secretary Thompson has put in place his own plan
for all HHS agencies to address chronic homelessness. NAMI supports
these efforts, but also believes that SAMHSA can do more to ensure that
its programs more effectively address the needs of individuals with
severe mental illness and co-occurring disorders experiencing chronic
homelessness (i.e., staying homeless for a year or more).
First, as part of the Samaritan Initiative, Congress should
authorize and fund a new program to finance services in new and
existing permanent supportive housing developed by HUD's McKinney-Vento
Homeless Assistance Act. NAMI, along with our colleagues at the
National Alliance to End Homelessness and the Corporation for
Supportive Housing, have our own proposal on services in permanent
supportive housing--ELHSI (Ending Long-Term Homeless Services
Initiative). What is key is that existing and future permanent
supportive housing have stable funding for services to ensure that
individuals are able to make the transition to stable lives in the
community.
Finally, NAMI would urge this Subcommittee to examine the current
problems with the funding formula associated with the PATH program at
CMHS (Projects for Assistance in Transition from Homelessness). This
critically important program funds outreach and engagement services for
homeless individuals in shelters and on the streets. Since fiscal year
1997, Congress has nearly doubled funding for PATH, up to $50 million
requested for fiscal year 2004. Unfortunately, more than 20 rural and
frontier States have seen their allocation of PATH funds frozen as a
result of artificially low minimum State allocation. Likewise, the
current formula resulted in four States (Alabama, Missouri, New York
and Ohio) actually losing funds in fiscal year 2003 despite a $3
million increase provided by Congress.
5. SAMHSA should expand its efforts to address the growing and
disturbing trend of ``criminalization'' of mental illness experienced
by adults in jails and prisons and adolescents in juvenile justice
programs.
Chairman DeWine, NAMI is extremely grateful for the leadership that
you have provided in Congress in bringing attention to this enormous
and growing problem. NAMI strongly supported your efforts in passing
legislation authorizing the Mental Health Courts program at the Justice
Department (P.L. 106-515). NAMI is proud to support your legislation
(S. 1194) to expand the ability of State and local law enforcement and
corrections systems to cope with their growing burden of responding to
offenders with a history of untreated severe mental illness--most of
them low-level nonviolent offenses.
As you know, effective jail diversion programs, Mental Health
Courts, and programs to help adult and juvenile offenders with mental
illnesses transition back into the community require close
collaboration and cooperation between corrections, courts and mental
health systems. Too often, mental health systems have been reluctant to
do their part to help these individuals, many of whom would not have
ended up in correctional systems had they received timely and
appropriate mental health services and supports. At the Federal level,
SAMHSA has worked collaboratively with the Department of Justice to
provide technical assistance and support for jail diversion and
community reentry programs for offenders with mental illnesses.
NAMI strongly urges that the SAMHSA reauthorization legislation be
utilized as an opportunity to expand the agency's current jail
diversion program and to expand the jurisdiction of this program to
include community reentry and transition for juveniles and adults with
mental illnesses exiting criminal justice systems. We also urge that
SAMHSA be encouraged to work even more closely with the Department of
Justice and other relevant Federal Agencies (e.g. the Social Security
Administration, the Center for Medicaid and Medicare Services, and the
Department of Housing and Urban Development) in carrying out these
important activities.
6. SAMHSA should continue its efforts to address the absence of a
coherent service system for children and adolescents with serious
mental illness.
The impending release of President Bush's New Freedom Commission
report on Mental Health will emphasize the wholesale fragmentation and
lack of coordination between various systems responsible for providing
treatment and services to individuals with mental illnesses across the
country. These problems are particularly profound for children and
adolescents who suffer from mental illnesses. It is well documented
that families of children with mental illnesses frequently have no
place to turn to access the services that their children need. As a
consequence, children with mental illnesses are even more
disproportionately represented in juvenile justice systems than adults
with mental illnesses are in adult correctional systems. Moreover, many
families are literally forced to give up custody of their children to
access care for their loved ones. This is a national tragedy.
As a first step, NAMI recommends that Congress establish, through
legislation, an interagency body on children's mental health to improve
collaboration, systems coordination, and blended funding of services
for children with mental illnesses across all relevant Federal
programs. SAMHSA, as the Nation's lead agency for mental health
services, should be vested with lead responsibility for this important
function.
Additionally, CMHS--through the Children's Mental Health Services
Program also funds the Comprehensive Community Mental Health Services
for Children and Their Families Program--provides grants to public
entities providing comprehensive community-based mental health services
for children and adolescents with mental illnesses. NAMI strongly
supports the Federal investment in creating home and community based
services for children with mental illnesses and their families. We look
forward to working with the Subcommittee to ensure that the program is
further improved so that children and adolescents with serious mental
illnesses receive services that are evidence-based, effective and
associated with outcomes that are tracked to ensure accountability.
Conclusion
NAMI is deeply grateful for the opportunity to offer our views on
SAMHSA reauthorization legislation. We look forward to working with you
and your colleagues on this legislation and other matters that will
come before this Subcommittee.
Senator DeWine. Let me thank our panel. I will start with
Mrs. Taft.
I was interested in your comment about the expanded use of
CSAP information by other Federal agencies, and I wonder if you
could comment about how well you think they are doing now; and
also, if you could comment about Director Curie's testimony in
regard to where CSAP has been, where CSAP is, and where CSAP is
going.
Mrs. Taft. Thank you, Mr. Chairman, for that question.
I believe that CSAP is finally beginning to grow into its
rightful position of being the source in the Federal Government
where all agencies and departments should come for accurate
research-based information. I do not believe that has been the
case in the past. I think that there continue to be some
conflicts among the major funding sources for prevention
activities at the State and local level in this regard, but I
am hopeful that, with continued nudging from Congress, CSAP
will become the accepted leader in prevention activities.
Senator DeWine. So we are moving in the right direction.
Mrs. Taft. I think we are moving in the right direction.
Senator DeWine. More agencies need to look toward CSAP, in
your opinion.
Mrs. Taft. Yes. CSAP in my opinion--the research-based
information has the ability to turn that into programs and
strategies and practice that are effective and should be looked
to as the final word in what is effective and what is not.
As you know, the field has developed tremendously since you
authored the Drug-Free Schools report. In fact, at that time,
it was just Drug-Free Schools report, and since then, it has
become the Safe and Drug-Free Schools, and it keeps getting
watered down in its approach, and that is why it is really
important that CSAP stay strong and can work toward a unified
approach.
The whole field has been evolving and changing, and we have
continued to learn what is effective and what is not effective,
and CSAP has been doing a good job of getting that information
out to the field. Now that we have got a good base of knowledge
of effectiveness and what works and what does not work, we need
to continue to build on that, to get that information out to
the field, and to make sure that all children in the United
States can benefit from that knowledge.
Senator DeWine. Thank you.
Dr. Gallant, I wonder if you could tell me about the Synar
Amendment which we keep waiving, and if you have any
suggestions about changes that we should make in regard to
that. We all know the intent of the Synar Amendment, and it is
a good intent, but we keep waiving it. And we understand why we
waive it--everyone is well-intended here--but what are we doing
to do about that?
Mr. Gallant. Mr. Chairman, as you indicated, we are very
supportive of the intent of Synar and see ourselves as really
contributing to reducing the effects of tobacco. However, that
is now why we exist in most States systems; it is not to reduce
youth tobacco use. We believe that Synar would be better-
positioned if it were located in one part of Health and Human
Services. We believe that the Centers for Disease Control and
Prevention has a tobacco control program that has operated for
a number of years, and we believe that Synar would be better-
positioned there. We also believe that the penalty structure
associated with Synar should be eliminated, and that States
should be incentivized to reduce youth access to tobacco.
Senator DeWine. So a carrot instead of a stick.
Mr. Gallant. That is right, Senator.
Senator DeWine. Will that work?
Mr. Gallant. I think it would work far better than to hold
a penalty over State systems, particularly for that part of the
system that is trying to deliver a service that is already with
lack of capacity, so to move it to CDC with their tobacco
control efforts. And I think you will also find that most State
health departments already have a major role and are accepted
by both the executive branch and the legislative branch to have
a public health promotion role, including tobacco control. So
to put it all in one area I think would increase its impact,
would probably make it far more effective, and would probably
achieve even better results than we have been able to with our
efforts.
Senator DeWine. Well, it is not working, but just to State
my public position, I am not willing to give it up. We have to
make it work some way. It is not working now, but we just
cannot give it up. We just have too much at stake here from a
health point of view, and we have got to all try to figure it
out, and you can help us--not just you, but everybody else on
the panel, everybody in the room--can help us figure out a way
of making this work. In the next few months, we need to work on
that.
Mr. Gallant. We are committed to do that, Senator.
Senator DeWine. Senator Reed?
Senator Reed. Thank you very much, Mr. Chairman, and let me
thank the panel for their excellent testimony.
And Mrs. Taft, let me thank you for your testimony and also
for your gracious leadership as the First Lady of Ohio. It is a
pleasure to see you here today.
You cited several studies in your written testimony of
programs that are successful in reducing drug and alcohol use
among children. In your estimation, why are these programs
effective? Is there something that you have sensed, certain
elements that make them successful?
Mrs. Taft. According to what CSAP tells me, when you can
increase the perception of harm and can increase the perception
of social disapproval, use among young people will go down. So
many, many of the most effective programs now are those that do
those two things. And those are usually things that happen in a
global sense and are environmentally induced through regulation
or through social norms that happen in the community. Then, if
you can combine those with programs that give young people life
skills that are necessary to refuse alcohol and drug use, you
usually come up with success.
Senator Reed. Thank you very much. Have you seen any of
those programs in action in Ohio, because I am sure you are out
and about all through the State.
Mrs. Taft. Yes. In fact the Pride Survey that happened last
year in Ohio showed that Ohio was below the national averages
among alcohol, tobacco, and other drug use. So I see a lot of
those good programs working.
Senator Reed. Thank you very much.
Dr. Gallant, thank you for your testimony also. I want to
give you the opportunity, because I notice a trend on the
panel--have you ever visited Ohio?
[Laughter.]
You should claim that right away.
Mr. Gallant. Yes, Senator, I have, and I will be going
there this Thursday.
Senator Reed. I thought that was happening.
You and your organization play a critical role, and as
Administrator Curie suggested, in the Access to Recovery
proposal. There is going to be a tremendous role for State
substance abuse officials. What role have you had to date in
preparing for, commenting on, and participating in the
development of the Access to Recovery approach and what role do
you anticipate going forward?
Mr. Gallant. We have had a role. Mr. Curie and his staff
have involved us in discussions about the thinking around the
Access to Recovery Program. They have involved several of our
State directors in helping them think through strategies in
terms of how they might implement this program.
We are, as are our State directors, waiting for the final
program to be developed so we can see the detail. But overall,
we think that this is a good third leg, as long as the block
grant remains as the foundation for our system and that the
Targeted Capacity Program remains as a way to target special
issues and needs, and I think this third leg might allow us to
expand in a new and innovative way. But we are waiting to see
the details.
Senator Reed. Very good. As I suggested, and I think our
discussion indicated, there are some very, very difficult
issues, technical as well as constitutional, that you and your
colleagues will have to deal with.
The only other thing I would say is that there is a real
value in having State-level local initiatives, but there also
has to be some kind of common baseline nationally, and I think
your organization can help guide us in that direction.
And thank you for your testimony, Ms. Knisley. You touched
on an issue that is very, very near and dear to me; we all wear
multiple hats around here, and I am the ranking member on the
Housing Subcommittee. There is a huge crisis in affordable
housing for a whole range of Americans, and it is particularly
exacerbated if you have a mental health issue or a substance
abuse issue. You touched on that, and I wonder what more can we
do from your perspective. You must see it every day in
Washington, DC.
Ms. Knisley. Yes, Senator Reed. As a matter of fact,
Washington, DC now has the dubious distinction of growing
faster in terms of unaffordability for a person with
disabilities. The recent report indicated that it now costs in
the District of Columbia 183 percent of your monthly disability
income for a one-bedroom market rent apartment. And obviously,
this is a huge issue for us.
We now have the technology, and if we apply our resources,
our practices have advanced to where we can help people sustain
their own living situation, their own home, their own
apartment. However, if we do not have affordable housing the
work that we are doing would be for naught in our department.
And I know it is a major initiative around the country with
other States and local communities, and we have got to have the
strong leadership of SAMHSA to see this true with their Federal
partners, particularly HUD.
But we have a major affordable housing initiative in our
community where I spend a lot of time with the housing finance
agency and with our public housing authority trying to make
sure that we have access to some of those resources coming into
the community, because it is never going to be enough.
So we are very, very concerned, and like I said, we have
some newer housing strategies like Housing First, where we help
someone get into a place and then be able to stay there. It is
a very promising practice, but without the affordability of
housing, we are facing a huge uphill struggle.
Senator Reed. Sometimes I fear that despite all the
improvements and all the resources that we are providing to the
mental health and substance abuse community, unless we
effectively deal with the housing issues, which are expensive
and difficult, you are just treading water, and we are never
going to get to the point where we have a system that works,
because if you cannot find a place for someone to live, you
cannot adequately deal with their other issues, and frankly, if
it is a transient placement, you will lose that person. So I
just see this as a very critical issue.
Ms. Knisley. Absolutely. One thing I should add to that,
Senator Reed, is I think we have learned now the value of a
person in their own home, the value that that has to their
rehabilitation and recovery, because as an individual
recovering from mental illness, if you can see the progress you
can make, and you can have your own place to live, while we
need good treatment facilities, living for a long-term in a
congregate setting is just not something that is a natural
place for people to be.
So we see this value, and we have seen this value
repeatedly. We even have research results that show that for
people who can be living in their own place and rebuilding
their lives, this has a tremendous influence on their recovery.
Senator Reed. In the scope of our reauthorization of
SAMHSA, I hope we have the opportunity to develop some of these
issues of interagency coordination, of the complementary nature
of good, affordable housing, and mental health services and
substance abuse treatment, because I think it is an important
point, as you do.
Let me ask another question, Ms. Knisley. Administrator
Curie talked about the new Performance Partnership Grants and
the Access to Recovery initiative. You are engaged in a whole
host of programs right now which are time-consuming and
difficult. Then there is another level being proposed which
requires more parameters, more metrics.
Can you comment about the assistance you need, the
technical assistance, the additional administrative resources,
to make sure that we do this right and that we actually have
performance grants that accurately measure performance rather
than just accumulate lots more statistics?
Ms. Knisley. Senator Reed, I think it is a very important
question, and NASHPD and the mental health commissioners
appreciate the opportunity to work with SAMHSA in formulating
those grants. I know that in my situation, I have performance
goals for Mayor Williams; that is very important as we are
building our new mental health system here in the District. We
are trying to come out of a longstanding receivership in mental
health, so I have goals for the Federal court, and then the
partnership goals and objectives that we need to meet. If we
can marry those, and if we can find the least common
denominators for reporting data and have that interchanged with
SAMHSA to see that we can get there, so the States are not just
creating another database, then I think that is a very
important piece that we must work on.
The second issue is technical assistance. Public mental
health systems have traditionally been underfunded, so
therefore our information systems have been traditionally
underfunded. And we do not have and have not in the past had
the type of technical expertise to do this well, and it ends up
costing us more money because we have not been able to put the
R and D into it correctly in the first place. So it is very,
very important.
It is also very important for us to consider as we talk
about this integration, it is so necessary in our case with
child welfare, or in the housing world or with criminal
justice, that we are not reporting slightly differently to
another entity if we are sharing resources. We have got to find
a way at the Federal level to bring these different systems
together on reporting, and even with our colleagues in
substance abuse where they may be reporting--although I think
we do a better job with substance abuse because we are married
in many ways. But it is still very important that we get a
common database, common information, common performance.
Senator Reed. Thank you.
Mr. Chairman, my time has expired, but I just want to thank
Ms. Walker for her wonderful testimony and for being here
today. The chairman might have a question for you, but I just
want to thank you for participating, and the whole panel, thank
you very much.
Ms. Walker. Thank you.
Senator DeWine. Senator Reed, thank you very much.
I have several questions that Senator Kennedy has
submitted, and I am going to read these two questions on behalf
of Senator Kennedy.
The first is for Mrs. Taft--it is an easy one, really, it
is. It is a short one, too. ``How effective have we been in
this country intervening with children whose mothers are
substance abusers?'' This is a very important question.
Mrs. Taft. It is a very important question, because I think
the future of prevention and treatment really hinges on how
well we do that. The whole issue of fetal alcohol syndrome and
fetal alcohol effects and drug-induced deliveries of babies is
a big one. It makes those children much more vulnerable to
later use on their own and usually puts them in a very
dysfunctional family that has all kinds of consequences on
their mental health and their ability to learn.
In Ohio, which I can speak the most about, we are doing a
lot in this area, and I keep hearing about efforts at the
national level to foster more efforts at the local and State
level on trying to get mothers to deliver very healthy babies.
Senator DeWine. I think we have come a long way.
Mrs. Taft. I think we have, too. I think we have a lot more
distance to travel, though.
Senator DeWine. And we have a long way to go.
Mrs. Taft. Yes.
Senator DeWine. Senator Kennedy has a question for Gloria
Walker. Ms. Walker, Senator Kennedy says, ``I agree with you
that treating co-occurring mental illness and substance abuse
should be a top priority. In the November 2002 Report to
Congress on the Prevention and Treatment of Co-Occurring
Substance Abuse Disorders and Mental Disorders, the U.S.
Department of Health and Human Services suggests that many
States and providers need to change old approaches for new
evidence-based treatment practices. How can this
reauthorization address this problem?'' How can we approach
this as we deal with the bill that we are going to be working
on for the next many months?
Ms. Walker. I think the answer has already been given, and
that is with integrated treatment, being able to treat
substance abuse and mental illness together, which is a
problem, fundamentally a problem, because of the financial
structure. So I think that is something that definitely has to
be addressed, how they will be able to do it and integrate the
funding so that a person with mental illness can also be
treated for substance abuse as well.
Senator DeWine. Does anyone else want to add anything to
that?
Ms. Knisley, you look like you were ready to add
something--that is why I asked. You look like you were ready to
go there, and that is why I asked.
[Laughter.]
Ms. Knisley. Senator DeWine, I think absolutely the
integration. We know today that we have effective interventions
for treating both substance abuse and mental illness at the
same time. And historically what would happen is that you would
treat substance abuse first and then a mental health problem. I
can remember as a clinician trying to figure out, well, do I
drive this person who is intoxicated around until they sober up
so I can get them into a mental health treatment facility, or
do I hope that when we go to be assessed for substance abuse
treatment, they are not going to say, ``He is a mental health
problem; take him there.'' And I can remember driving around in
Columbus, OH for hours trying to find someone who would not ask
does he have the other illness.
Today we can treat both, and we do. However, we have got to
integrate the funding and the policies to make that work in all
of our States, and I think that is exactly what Ms. Walker was
saying and what we would promote.
And in the report to Congress on co-occurring disorders
that was presented last winter, there are many good examples of
programs that could do just that.
Senator DeWine. How does that translate into what we do as
far as legislation?
Ms. Knisley. I think it translates in several areas. One
that is in the SAMHSA reauthorization is to look at the
separateness of the block grants. And again, I think we do not
want to dilute the block grants--and I am sure that my
colleague Dr. Gallant would very strongly say we do not want to
see all of a sudden a substance abuse block grant becoming a
mental health block grant or vice versa--so we are not looking
at diluting those, but we are looking, I believe, for very
strong language about models for integration of programs where
we can bring the two funding structures together.
So I think that would be one important area in the
reauthorization. And I think second in the reauthorization is
to look at this report on co-occurring disorders for other
policies that we can effect that you would urge SAMHSA in the
reauthorization to work on with us. And I might add again that
I think it is very important, Senator DeWine, when we look at
the criminal justice population who have mental health
disorders, you are going to see a co-occurring disorder almost
every time.
Senator DeWine. Yes, almost every, single time, absolutely.
Ms. Knisley. Yes. So as we look at that legislation and the
policies there, I think that concurrent treatment is going to
be absolutely essential. For example, when we are trying to get
someone out of jail today in the District, what we do is try to
provide counselors who are going to be treating both
disabilities at the same time, and I think it is very important
to stress that in the legislation.
Senator DeWine. Ms. Walker and Director Knisley, in your
testimony, you both recommended that Congress should legislate
an interagency body on children's mental health to improve this
collaboration in providing services for kids. How do you see
SAMHSA handling the concerns of children now, and how would
this body improve access to services for children? How would
this work?
Ms. Knisley. I will start it off. I think the first thing
about the body is that--well, let me back up and say first of
all that SAMHSA is doing a terrific job with the Systems of
Care work that they have been doing around the country. The
District of Columbia has just been awarded one of the Systems
of Care Organizing Grants, and we have had superb technical
assistance and support. It is a cooperative agreement with the
Federal Government, and they have done an outstanding job.
Ohio was one of the very first grantees of this program in
the mid-eighties, and I would have to say that, other than our
work on brain disorders that has been supported so very well by
Congress, this is the other major area where we have seen the
most movement in mental health services. And I know that Mr.
Curie, with his background in this area, has continued to push
hard to develop these systems of care.
So we think that SAMHSA is doing very well in this area--
but there is even more leadership that is needed. And as you
know working here with the District, we have got to find as
many ways as we can to work with our child welfare system and
our juvenile justice system, and sometimes when you do not
bring that body together through legislation, the demands of
those other programs just take over on a day-to-day basis, for
very practical reasons. So we have got to find a way to
legislate this. The results will be so much more positive for
our children, even though going in, it says, well, an
interagency body is additional work and so forth and so on, but
the results are there; they are just outstanding. And we have
seen many States with these legislative bodies that have worked
very, very well, and we trust that the same would happen at the
Federal level.
Senator DeWine. Good. Ms. Walker, do you have anything to
add to that?
Ms. Walker. No, I have nothing to add.
Senator DeWine. Well, I want to thank the panel. I think we
have had a very good first hearing. Dr. Gallant, we do not want
to exclude you as the only nonOhioan here. We appreciate your
service very much.
Ms. Knisley. We will let him in, right?
Senator DeWine. That is right. And Ms. Knisley, we
appreciate your past service to Ohio very much, as past
director; and Ms. Walker, we appreciate your continued good
work in Cincinnati and around the State and across the country.
And of course, Mrs. Taft, we appreciate your good work. You and
I have worked together as Ms. Walker and I have, and we just
appreciate your good work and your great leadership for the
State, and we appreciate the testimony here today.
The reauthorization is an important bill as we move forward
with these two very, very important constituencies and
important issues, and this committee is going to hold a number
of additional hearings, fact-finding hearings. We want to get
it right, and I think we have a good bill to build on, a good
history to build on, and we want to learn whatever we can learn
to make sure that we get it right.
So we appreciate this hearing, and we appreciate your good
input. Thank you all very much.
The subcommittee is adjourned.
ADDITIONAL MATERIAL
Prepared Statement of Michael Faenza
The National Mental Health Association (NMHA), the country's oldest
and largest nonprofit organization addressing all aspects of mental
health and mental illness, looks forward to working with the Committee
as it embarks on the important work associated with reauthorization of
the Substance Abuse and Mental Health Services Administration (SAMHSA).
In partnership with our network of 340 State and local Mental
Health Association affiliates nationwide, NMHA works to improve
policies, understanding, and services for individuals with mental
illness and substance abuse disorders, as well as for all Americans.
Established in 1909 by a mental health consumer, NMHA's philosophy has
consistently been that the needs of consumers and communities must be
at the center of all policy and practice concerns in the mental health
and substance use fields.
NMHA's symbol is a bell, a bell cast from shackles and chains
widely used in this country by State institutions that warehoused
people with mental illnesses. The cruel history of what passed for care
of people with mental illnesses is almost unspeakable. Suffice it to
say that that history is marked by ignorance, loathing, and fear. Those
shackles and chains are gone, but the underlying stigma and ignorance
surrounding mental illness and substance use are not.
Thus, we welcome the Subcommittee's dedicated focus on mental
health and substance use services, a focus we hope will help erase the
long history of stigma surrounding mental illness and substance use and
help shape Federal policy to provide greater priority to these
important public health problems.
Deliberations on SAMHSA reauthorization arise at a critically
important time. First, of course, we anticipate the imminent release of
the final report of the President's New Freedom Commission on mental
health. The Commission's interim report has already provided a much-
needed appraisal of the grave societal problems associated with the
failure to make mental health a priority in this country. Indeed its
hard-hitting assessment that the public mental health system is ``in
shambles'' is a riveting message that should prompt an equally hard-
hitting response. The Commission's final report, recommendations and
subcommittee papers will give the Administration, Congress and the
mental health community a critical foundation for needed action.
Indeed, publication of the Commission's report, this hearing and those
that may follow have a distinct urgency because they take place against
a backdrop of real crisis.
Last year, in announcing plans to establish a mental health
commission, the President stated that ``our country must make a
commitment: Americans with mental illness deserve our understanding and
they deserve excellent care.'' Yet, he acknowledged, many people now
``fall through the cracks of the current [mental health] system.''
The cracks in the mental health system are growing wider as States
and localities grapple with record budget deficits. Recent estimates
place collective State budget deficits for the 2003 fiscal year around
$26 billion. In fiscal year 2004, States have reported $68.5 billion in
shortfalls, an estimate that is expected to grow substantially in the
coming months. In addition, the Federal budget continues to underfund
effective, science-based mental health services, thus widening the 15-
plus year gap between scientific discovery and community services
application.
THE CRISIS IN THE PUBLIC MENTAL HEALTH SYSTEM
As was highlighted in the landmark 1999 report, Mental Health: A
Report of the Surgeon General, there are vast disparities in
availability and access to mental health services in this country,
despite the enormous scientific and medical advances that have been
made in the diagnosis and treatment of mental disorders.
The interim report of the President's Commission is bluntly frank
in stating that ``the mental health service delivery system needs
dramatic reform'' because ``it does not adequately serve millions who
need care.'' In fact, one out of every two people who need mental
health treatment don't receive it, and the rate is even lower--and the
quality of care poorer--for ethnically and racially diverse
communities. The report describes the system as ``fragmented and in
disarray . . . from underlying structural, financing, and
organizational problems.'' Those failings ``lead to unnecessary and
costly disability, homelessness, school failure, and incarceration,''
the Commission reported.
The mental health delivery system in this country has long been
underfinanced and overburdened. But economic recession and a rapid
transition from budget surpluses to sharp deficits in 44 of the 50
States have placed their mental health systems in real jeopardy. Nearly
two-thirds of States cut funding in 2002 for mental health services,
and most States anticipate further cuts for the coming fiscal year.
Such cuts mean further strains on the already under-funded public
mental health system. States have already instituted such measures as
reducing benefits, increasing the cost-sharing burden on low-income
Medicaid recipients, requiring prior authorization for certain services
(including mental health services); limiting access to needed
medications through formularies and other mechanisms, and reducing the
rates to providers. These cuts appear to be just the beginning. The
situation in 2003 is proving even more challenging as State after State
has moved to cut funding for mental health services, reduce Medicaid
eligibility levels, and restrict access to medications.
MENTAL HEALTH REFORM
The crisis in public mental health around the country requires more
than just fiscal relief. It also requires fundamental reform of the
nation's mental health ``system.'' We are proud to join fellow
advocates in the mental health community in pressing for such reform,
and urge the Committee to make realization of mental health reform a
priority in your work on SAMHSA reauthorization.
What is ``mental health reform?'' The Campaign for Mental Health
Reform which NMHA and sister mental health organizations are launching
proposes no single ``fix.'' Nor does the President's Commission. But
the call for mental health reform seeks to ensure that people of all
ages with mental disorders do not fall through the cracks--that lives
are not lost, and that recovery becomes a realistic goal. Mental health
reform calls for mental illnesses to be treated with the same urgency
as all other medical illnesses, and calls for recognition that mental
health is fundamental to health. Importantly, real reform requires
national leadership and the adoption of specific policies to align now-
fragmented systems to deliver needed services rationally and to achieve
markedly improved quality.
Certainly, equal access to mental health care is a key goal we hope
this committee will adopt, cognizant of the findings of the Commission
and the 1999 Surgeon General report that we are far from that goal. The
barriers to equal access are formidable: lack of mental health parity
in public and private insurance benefits, lack of parity in Federal
funding relative to the prevalence of mental disorders and their
resultant disability burden, and the enormous barriers stemming from
poverty and the widespread failure to adapt service-delivery to unique
cultural norms of those with mental health needs.
Eliminating barriers to care--while critical--is itself only a
first step. Mental health reform must also concern itself with the
organization, financing, and quality of services provided, and with the
goals of full community participation for children and adults and
recovery from mental illnesses. We must be mindful not only of the vast
numbers of people who do not receive needed mental health care, but of
how often the services provided are inadequate and inappropriate.
We speak colloquially of the problems affecting the ``mental health
system.'' But as the President acknowledged in creating the Mental
Health Commission, what we have instead is a fragmented delivery system
in which people with mental disorders have contact with multiple,
disconnected systems, including primary care providers, mental health
service providers, hospitals, schools, child welfare programs, homeless
shelters, substance abuse treatment facilities, and--sadly and too
often--the justice system. Service provision is frequently based on
what a system is willing to pay for, what is available in a particular
geographic area, or what a provider is trained or willing to do, rather
than on individual need and the application of state-of-the-art
treatments and best practices. Not surprisingly, many people fall
through the cracks altogether, leading some to refer to our nation's
``non-system'' of mental health delivery.
THE NEED FOR A STRONG SAMHSA
During this time of unprecedented crisis and opportunity in the
mental health field, the importance of a strong Federal role for SAMHSA
cannot be overstated. NMHA is a member of the Campaign for Mental
Health Reform, which is also submitting testimony today. The Campaign's
testimony discusses the need for Congress to provide SAMHSA with the
funding and authority to help achieve system reform. In addition,
following are some specific concerns that we would encourage the
Committee to consider as it reviews SAMHSA's programs and authorities.
As the President's Commission has noted, mental health is
a public health issue. Like other major public health issues, it
requires a public health approach. It is critical that we meet the
complex needs of those with chronic mental illness. But we must also be
concerned with the mental health of the entire community. Mental health
issues touch virtually everyone at some point in their lives. To be
truly effective, the mental health system must work in collaboration
with other health and human service systems and focus on mental health
over the lifespan. We urge support for policies and corresponding
appropriations for SAMHSA that emphasize screening, prevention, the
promotion of mental health, and access to treatment and services.
To illustrate the point regarding mental health and public
health, one need only consider that the shocking attacks of September
11, 2001 targeted not only major national centers but our national
psyche. Many Americans, especially children, bear psychic scars and
lingering symptoms from the trauma of that horrific attack and the
ongoing terrorist threat we face. The very purpose of terrorism is to
create destabilizing psychological trauma. But despite our
vulnerability to future terrorism, this country lacks the capacity to
provide an effective mental health response to wide-scale disaster.
This remarkable lack of preparedness in the face of an ongoing
terrorist threat is itself a public health risk that must be faced. We
urge the Committee, accordingly, to make the mental health aspects of
disaster-preparedness a high priority for SAMHSA in reauthorization
legislation.
As inadequate as the adult mental health system is, the
situation is even worse for children. When children's mental health
needs are addressed at all, the system for serving them is often
treated as an extension of the adult system, and as a result truly
child- and family-focused service planning and delivery is in short
supply. In many cases, children with mental disorders are not served at
all by the mental health system, but end up instead in other systems,
such as juvenile justice. Across the country, young people with unmet
mental health and substance abuse problems languish in juvenile
detention facilities for lack of community resources. The confusion and
neglect surrounding the needs of children and adolescents with
emotional, behavioral, and learning problems is tragic and
unacceptable. We urge the Committee to give particular attention to the
needs of children and to support policies that facilitate collaboration
among child-serving systems, including mental health, substance abuse,
education, child welfare, juvenile justice, and primary care. We also
urge you to support approaches that maximize child and family access to
mental health services, such as the establishment of school-based
mental health services and the ``systems of care'' approach employed by
the Comprehensive Community Mental Health Services for Children and
Their Families program.
The Commission's important emphasis on the fragmented
nature of mental health service-delivery highlights the need to foster
cross-agency systems of care as a means of integrating the provision of
needed services. But the Commission also wisely recognizes the role of
the mental health consumer in his or her own care, and should be
credited with emphasizing the vital role that ``consumers'' have in
their own path to recovery. As the Surgeon General's 1999 report on
mental health also recognized, supporting and promoting consumer-run
mental health services provides enormous support to people in their
recovery from mental illnesses. In that regard, we urge the Committee
to examine and give appropriate statutory recognition to the role that
consumer self-help and technical assistance (TA) targeted to consumers
play in recovery.
We urge the Committee to take cognizance as well of the
role that community-based organizations play in stimulating mental
health reform. With the critical need for more, and more effective,
community-based mental health and substance-use services and the need
to engage multiple governmental agencies to replace service-
fragmentation with service-integration, one cannot overemphasize how
critical a catalyst community-based organizations can be. The Center
for Mental Health Services has long administered a program of community
action grants to foster such community-planning toward improved
service-delivery. Yet this relatively modest, highly effective grant
program (along with consumer TA centers) has fallen prey to ill-advised
budget cutting. We urge the Committee to use reauthorization as a means
to shore up cost-effective programs like community action grants and
consumer and other technical assistance services.
Finally, with all the problems associated with mental
health service-delivery, it is critical to recognize, as the
President's Commission did, that both access to mental health services
and the quality of those services, are worse for ethnically and
racially diverse communities than for the general population. To be
effective, service delivery systems must address and respect the
diversity among people and cultures. Instead, we have a system in which
certain racial and ethnic communities, as well as other underserved
populations, face glaring disparities in accessing culturally
appropriate mental health services. We urge the Committee to consider
proposals to focus Federal and State agencies on the mental health
needs of underserved communities as an important component of needed
reform.
We look forward to working with the Committee on a mental health
reform agenda, one component of which is ensuring a strong Federal role
for the Substance Abuse and Mental Health Services Administration.
Thank you for this opportunity to share our views and concerns about
these critically important issues.
OHIO STUDENT SURVEY 2002
[Whereupon, at 11:50 a.m., the subcommittee was adjourned.]