Terry L. Cline Ph.D.
Substance Abuse and Mental Health Services Administration
U.S. Department of Health and Human Services
FY 08 Budget Proposal
Committee on Appropriations
Subcommittee on Labor, Health and Human Services, Education, and Related Agencies
U.S. House of Representatives
Thursday March 1, 2007
Mr. Chairman and Members of the Subcommittee, I am pleased to present the President’s Fiscal Year (FY) 2008 Budget Proposal for the Substance Abuse and Mental Health Services Administration (SAMHSA) within the U.S. Department of Health and Human Services (HHS). Overall, the President has proposed nearly $3.2 billion for SAMHSA in FY 2008. This is a net program level decrease of $159 million from the FY 2007 continuing resolution appropriation level. While this represents a 5 percent overall reduction for SAMHSA from the FY 2007 appropriation, we have once again set an aggressive agenda that supports our vision of a life in the community for everyone and our mission of building resilience and facilitating recovery.
To advance our Nation’s health and achieve wise fiscal stewardship of the taxpayers dollars Secretary Leavitt outlined criteria for the development of our FY 2008 budget proposal. Based on the criteria we looked for one time expenditures that do not need to be replicated; we prioritized delivery of services; we looked for completed functions and commitments within grants and scrutinized automatic renewals; we eliminated programs with purposes addressed other places; we scrutinized underperforming programs and programs without solid performance measures; and we looked for areas that had proposed reductions in the past that were not enacted.
As a result, the focus of SAMHSA’s FY 2008 Budget is on our service delivery programs. It maintains the same level of funding as the FY 2007 Continuing Resolution for the programs that are critical to the nation’s mental health and substance abuse service delivery system infrastructure, such as the Mental Health and Substance Abuse Block and Formula Grants. We are also investing available resources in program priority areas such as children’s mental health services, suicide prevention, school violence prevention, prevention and treatment of Post Traumatic Stress Disorder, the Screening, Brief Intervention, Referral and Treatment program, HIV/AIDS and criminal and juvenile justice. And, we continue funding for Presidential initiatives, including Access to Recovery, Mental Health System Transformation and creating a Healthier US through the Strategic Prevention Framework. The success of these SAMHSA’s programs, Presidential initiatives and service delivery systems clearly hinges on collaboration. No single agency can do it all. Without exception, partnerships among private sector and Federal, State and local public sector agencies are key to helping provide people with mental and substance use disorders the opportunity to achieve a fulfilling life in the community.
One of our public partners is the National Institutes of Health. In brief, the NIH Institutes develop evidence-based practices through research and SAMHSA supports implementation of evidence-based practices through grants that support service delivery. This partnership forms the basis of our Federal efforts to ensure the best science is used in our service delivery systems or as I call it “Science and Service.” To advance “Science and Service,” SAMHSA works with the National Institute on Drug Abuse (NIDA), the National Institute on Alcohol Abuse and Alcoholism (NIAAA) and the National Institute of Mental Health (NIMH) to establish pathways which will move research findings more rapidly into community-based practice and reduce the recognized 15-20 year gap between the initial development and widespread implementation of new and effective prevention and treatment services.
One example of our work to ensure consumers and providers of mental health and substance abuse services are aware of the latest interventions, treatments and recovery support services is our National Registry of Evidence-based Programs and Practices (NREPP). NREPP is a web-based decision support system designed to help States and community-based service providers make informed decisions about interventions they select to prevent and treat mental and substance use disorders. I have provided you with a handout that includes examples of the type of interventions listed on NREPP. The NREPP system is the culmination of a multi-year process that included input from numerous scientific and health care service experts and the public. Initially it will provide information on 27 interventions. Two-thirds of these received NIH funds for development and testing. Currently, over 200 interventions are in the queue for review and with adequate funding we expect to be able to add 10 to 20 interventions to the Registry every month.
An excellent example of one program listed on the Registry is the Matrix model for treatment of methamphetamine addiction. The evolution of the Matrix model provides a clear-cut example of what we mean by “Science and Service.” The treatment model was developed to address cocaine addiction through funding from NIDA. SAMHSA demonstrated the effectiveness of the model for methamphetamine treatment and expanded use of the model by States and community-based providers. As investments in research provide evidence of effectiveness of new interventions, SAMHSA will continue support the acceptance and adoption of evidence based interventions through requirements in services grants and training.
Through budget formulation and program implementation, SAMHSA has continued to sharpen its focus and set our priorities as a service delivery agency. In FY 2008 SAMHSA will continue to expand substance abuse treatment capacity in new and innovative ways; strengthen and streamline substance abuse prevention efforts on a national scale; implement the Federal Mental Health Action Agenda to achieve transformation of the nation’s mental health services delivery system; and increase accountability and improve service quality through data collection.
EXPANDING SUBSTANCE ABUSE TREATMENT CAPACITY
Annually, more than twenty million Americans struggle with a serious substance abuse problem for which treatment is needed. Substance abuse leads to lost productivity, domestic violence, child abuse, criminal involvement, and premature and preventable deaths. The economic cost to the Nation is conservatively estimated to be over $246 billion. The FY 2008 Budget includes $2.3 billion to support substance abuse prevention and treatment activities. A total of $1.8 billion is requested for the Substance Abuse Prevention and Treatment Block Grant, the same level as FY 2007. These funds form the cornerstone of States’ and Territories’ substance abuse prevention and treatment activities.
SAMHSA’s Center for Substance Abuse Treatment’s (CSAT) budget level for Programs of Regional and National Significance (PRNS) is $352.1 million, a net decrease of $46.9 million. Within the CSAT PRNS budget line, SAMHSA continues to expand substance abuse treatment capacity through the innovative Access to Recovery Program. Access to Recovery (ATR) is a Presidential initiative that, through the use of vouchers, provides clients the opportunity to choose among a broad array of substance abuse treatment and recovery support service providers, including faith-based and community-based providers. The Budget includes $98 million for grants administered by States and Tribal organizations and an evaluation of the program.
Within Access to Recovery, $25 million will support treatment for clients using methamphetamine. Methamphetamine abuse causes great harm to children, families, and communities, but it is a treatable problem. Overall, the outcomes for clients served through the Access to Recovery program are very encouraging. After receiving services through ATR, 81 percent of clients are abstinent from substances and 51 percent are in stable housing. Expanding substance abuse treatment capacity also has a direct link to shrinking rates of criminal recidivism. Upon discharge from the Access to Recovery program, 97 percent of clients have no involvement with the criminal justice system . This impressive rate reflects an 81 percent reduction among those who were involved with the criminal justice system at intake.
Additionally, drug treatment courts provide a successful alternative to incarceration and help to break the cycle of addiction, crime, incarceration, release, relapse, and recidivism. These courts enable stakeholders to work together to give individual clients the opportunity to improve their lives, including recovering from substance use disorders and developing the capacity and skills to become full-functioning parents, employees, and citizens. Close supervision, drug testing, and the use of sanctions and incentives help ensure that offenders stick with their treatment plans while public safety needs are met. The FY 2008 Budget includes $31.8 million, an increase of $21.7 million, more than tripling the number of grants since FY 2006 that support substance abuse treatment services for clients of juvenile, family, and adult drug treatment courts.
Early identification of substance use and substance abuse disorders also contributes to health cost-savings, improved health outcomes, and increased public safety by preventing progression toward addiction. Unfortunately, risk signs often go undetected in general medical settings. The FY 2008 Budget includes $41.2 million, an increase of $11.5 million, to support screening, brief intervention, referral, and treatment in general medical and other community settings.
Other CSAT PRNS include, the Targeted Capacity Expansion Grants (TCE-General) which includes $17.8 million in the FY 2008 Budget through which 48 new grants will be awarded; Grants to Benefit Homeless Individuals is funded at $32.6 million in the proposed Budget which will fully fund all grants; and the Minority HIV/AIDS and Substance Abuse Treatment Grant program is proposed at $63.1 million in the FY 2008 Budget which will fully fund all grant and contract continuations as well as provide 44 new grants.
STRENGTHENING AND STREAMLINING SUBSTANCE ABUSE PREVENTION EFFORTS
While expanding substance abuse treatment capacity and recovery support services is critical, it is imperative not to lose sight of the importance of preventing addiction in the first place by stopping substance use before it starts. The President’s FY 2008 Budget sets SAMHSA’s Center for Substance Abuse Prevention’s (CSAP) budget level for Programs of Regional and National Significance (PRNS) at $156.5 million, a net decrease of $36.4 million. The FY 2008 funding level will support 221 grants and contracts consisting of 153 continuations and 68 new/competing grants and contracts. The CSAP PRNS budget line continues funding for the Minority HIV/AIDS and Substance Abuse Prevention Grants at $39.4 million which will fund 67 new grants and continue all current grants and contracts. The Fetal Alcohol Spectrum Disorder Center for Excellence includes proposed funding of $9.8 million which will fully fund the Center for Excellence.
Also within the CSAP PRNS budget line, SAMHSA will continue the Strategic Prevention Framework grant program to accomplish the President’s aggressive goal to reduce youth drug use in America. By focusing our attention, energy and resources we, as a nation, have made real progress toward reaching the President’s goal. The most recent data from the 2006 Monitoring the Future Survey confirms that we have accomplished an almost exact achievement of the President’s goal of reducing youth drug use by 25 percent by 2006. What this means is approximately 840,000 fewer youth used illicit drugs in 2006 than in 2001. This is a clear indication that SAMHSA’s work with our many Federal and State partners, along with schools, parents, teachers, law enforcement, religious leaders and local community anti-drug coalitions, is paying off.
Although our work is far from over, prevention remains key and SAMHSA’s Strategic Prevention Framework (SPF) will continue to play an important role in achieving the goals of the President’s Healthier US Initiative. To more effectively and efficiently align and focus our prevention resources, SAMHSA launched the Strategic Prevention Framework (SPF) in 2004. The SPF State Incentive Grant Program is systematically implementing a risk and protective factor approach to prevention across the nation. The SPF program is reducing substance use and building resilience in America’s young people. The FY 2008 Budget proposes a decrease of $10 million from the FY 2007 Continuing Resolution for the Strategic Prevention Framework State Incentive Grant program. At a proposed Budget level in FY 2008 of $95.4 million, efficiencies will be realized through a reduction of all existing grants and contracts to 90 percent of the FY 2007 Continuing Resolution level.
However, the success of the framework will continue to be determined, in large part, on the tremendous work that comes from grass-roots community anti-drug coalitions. Along those lines, SAMHSA expects to continue working with the Office of National Drug Control Policy (ONDCP) throughout FY 2007 and into FY 2008 to support the over 750 grantees funded through the Drug-Free Communities grant program. Additionally, SAMHSA will continue to focus energy and take a leadership role in the prevention of underage drinking. The facts speak for themselves. Alcohol is the drug of choice among America’s adolescents, used by more young people than tobacco or illicit drugs. An estimated 10.8 million young people between the ages of 12-20 (28.2 percent of this age group) are current drinkers. Nearly 7.2 million (18.8 percent) are binge drinkers, and 2.3 million (6.0 percent) are heavy drinkers. We know that we need to change how America thinks about underage drinking if we are to see a significant reduction in the problem.
IMPLEMENTING THE FEDERAL MENTAL HEALTH ACTION AGENDA
Serious mental illnesses make it difficult to hold a job, go to school, relate to others, and cope with ordinary life demands. In any given year, approximately five to seven percent of adults have a serious mental illness and a similar proportion of children have serious emotional disturbances. Today there is unprecedented knowledge enabling people with mental illnesses to live, work, learn, and participate fully in their community. Transforming America’s mental heath services delivery system is necessary to improve health and opportunities for adults with mental illnesses and children with serious emotional disturbances.
The President’s FY 2008 Budget includes $807 million for mental health services, a net decrease of $77 million from FY 2007. The FY 2008 Budget includes $428 million, the same level as FY 2007, for the Community Mental Health Services Block Grant, which supports comprehensive, community-based systems of care for adults with serious mental illness and children with serious emotional disturbance. The FY 2008 Budget also maintains steady funding for major children’s programs as well as service and protection programs for vulnerable populations such as people who are homeless and people who are institutionalized.
The President’s FY 2008 budget sets SAMHSA’s Center for Mental Health Service’s (CMHS) budget level for Programs of Regional and National Significance (PRNS) at $186.6 million, a net decrease of $76.6 million. The FY 2008 funding level will support a total of 228 grants and contracts, consisting of 201 continuations and 27 new/completing grants and contracts.
Within the CMHS PRNS budget line, $19.8 million is proposed for Mental Health Transformation State Incentive Grants to support States in developing a comprehensive mental health plan and improve their mental health services infrastructure. States receiving awards expand the use of evidence-based practices, use technology to improve access to care, and engage consumers in shaping the system to meet their needs. A transformed mental health delivery system will have a direct impact on SAMHSA’s ability to improve services around suicide prevention, preventing school violence, improving children’s mental health, assisting in the transition from homelessness, and protecting the rights of individuals with mental illnesses.
Starting first with suicide prevention, SAMHSA views suicide as a preventable tragedy and has elevated the issue to a high-priority status within the agency. The reason for the priority is clear. In the past year approximately 900,000 youth during their worst or most recent episode of major depression made a plan to commit suicide, and 712,000 attempted suicide. This Budget includes a total of $33.5 million for suicide prevention, including activities authorized by the Garrett Lee Smith Memorial Act, suicide prevention for the American Indian and Alaska Native youth population, a 24-hour national hotline, and a Suicide Prevention Resource Center.
With regard to preventing school violence, SAMHSA collaborates with the Departments of Education and Justice through Safe Schools/Healthy Students (SS/HS) to support local partnerships to promote healthy childhood development and prevent substance abuse and violence. The Budget includes $75.7 million for School Violence Prevention, which will allow SAMHSA to support all current grants as well as 22 new grants under the SS/HS program. SAMHSA’s contribution to this interagency partnership helps support early intervention to address mental health needs as part of a comprehensive approach to preventing violence in schools.
Young people with serious emotional disturbance who receive help for their condition are far more likely to experience success in school and far less likely to enter the juvenile justice system or the institutional care system. The Budget includes $104 million for Children’s Mental Health Services for the development of comprehensive community-based systems of care for children and adolescents with serious emotional disorders and their families. Of children receiving services under this program last year, nearly 70 percent did not require interaction with law enforcement and nearly 90 percent attended school regularly.
The CMHS PRNS budget line also continues funding for National Child Traumatic Stress Initiative at $28.1 million and the Minority HIV/AIDS and Mental Health Programs at $10.3 million. Additionally, Homelessness continues to be a priority program area for SAMHSA as well. Approximately one-fifth of homeless individuals also have serious mental illnesses. Individuals with serious mental illnesses are homeless more often and have greater difficulty transitioning from homelessness than other people. The Budget includes $54 million to maintain support for an array of individualized services to this vulnerable population through Projects for Assistance in Transition from Homelessness (PATH).
Unfortunately, individuals who reside in treatment facilities represent a vulnerable population as well. Individuals with mental illnesses and serious emotional disturbances who reside in treatment facilities are particularly vulnerable to neglect and abuse. The Budget includes $34 million to maintain support for State protection and advocacy systems to protect these individuals from abuse, neglect, and civil rights violations. Approximately 80 percent of substantiated allegations of abuse and neglect that are reported to protection and advocacy systems result in positive change for the client.
SAMHSA staff guide positive change for consumers and the field on a daily basis. The FY 2008 Budget includes $93 million, an increase of $1 million from FY 2007, to support staffing and activities to administer SAMHSA programs and fund Federal pay cost increases. These resources support the majority of SAMHSA staff who plan, direct and administer programs, and provide technical assistance and guidance to States, providers, consumers and clients as well as to the general public. Part of the positive change for consumers and the field is an increase in accountability and improved service quality.
INCREASE ACCOUNTABILITY AND IMPROVE SERVICE QUALITY THROUGH DATA COLLECTION
SAMHSA is working to finalize our data strategy in the coming months. Our goal is to ensure that decisions related to SAMHSA’s priorities are based on the most comprehensive and accurate information available. Our data strategy ultimately resulted in the development of a core set of National Outcome Measures (NOMs) which track and measure meaningful, real life outcomes for people in recovery from mental illness, addiction and/or co-occurring mental health and substance use disorders.
The seven defined NOMs Domains are already being implemented through the Access to Recovery Grant Program, the Strategic Prevention Framework State Incentive Grant Program and the Mental Health System Transformation State Incentive Grant Program. They are also already being reported by a majority of States within the Community Mental Health Services and the Substance Abuse Prevention and Treatment Block Grants. Work is underway and is expected to be completed on the final three NOMs measures by the end of this fiscal year. At that point we expect all of the States will be reporting on all of the currently defined measures because of the partnership we have developed and progress made in implementing NOMs. Concurrent with this testimony we are releasing the most current National and State level NOMs data and status reports through our SAMHSA website homepage.
Ultimately, we will be able to report consistent, cross-year data allowing us to examine the impact of programs and changes over time. It just makes sense to use consistent measures across programs that have the main goal of building resilience and facilitating recovery. It also makes sense to keep Congress and taxpayers informed on the effectiveness of their investment in our programs. For the stakeholders of our services, however, these data find their greatest value as the means to assure that we are providing the best services to the citizens our funded programs serve and achieve the best outcomes possible within current standards of care and prevention.
Complementary to the National Outcome Measures data are SAMHSA’s national data on the prevalence, treatment, and consequences of substance use and mental illness in the United States from our National Survey on Drug Use and Health. SAMHSA also regularly collects data on drug-related emergency room visits and drug-related deaths through our Drug Abuse Warning Network (DAWN) and we are the national source of information on the Nation’s substance abuse treatment system through our Drug and Alcohol Services Information System (DASIS).
SAMHSA and the agency’s constituent base understand that the collection and use of data for performance measurement and management lead to informed decision-making and, ultimately, to the provision of better services. Improved services in terms of substance abuse prevention and treatment and mental health treatment equal more lives saved and more Americans leading meaningful and rewarding lives in communities across a healthier nation.
In conclusion, the President’s FY 2008 Budget proposal is a fiscally responsible budget that sets priorities and holds government programs accountable for real results. Clearly, we had to make hard choices about our programs, yet I believe our FY 2008 Budget reflects the areas that have the highest pay-off potential. The FY 2008 Budget aligns SAMHSA’s resources around creating systemic change, building solid, lasting improvements in the health and human delivery service system for consumers and their families.Mr. Chairman and Members of the Subcommittee, thank you for the opportunity to appear today. I will be pleased to answer any questions you may have.
Last revised: April 19, 2011