[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

                              ----------                              


                         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.]

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