<DOC>
[108th Congress House Hearings]
[From the U.S. Government Printing Office via GPO Access]
[DOCID: f:86828.wais]
RECOVERY NOW INITIATIVE
=======================================================================
HEARING
before the
SUBCOMMITTEE ON CRIMINAL JUSTICE,
DRUG POLICY AND HUMAN RESOURCES
of the
COMMITTEE ON
GOVERNMENT REFORM
HOUSE OF REPRESENTATIVES
ONE HUNDRED EIGHTH CONGRESS
FIRST SESSION
__________
FEBRUARY 27, 2003
__________
Serial No. 108-7
__________
Printed for the use of the Committee on Government Reform
Available via the World Wide Web: http://www.gpo.gov/congress/house
http://www.house.gov/reform
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COMMITTEE ON GOVERNMENT REFORM
TOM DAVIS, Virginia, Chairman
DAN BURTON, Indiana HENRY A. WAXMAN, California
CHRISTOPHER SHAYS, Connecticut TOM LANTOS, California
ILEANA ROS-LEHTINEN, Florida MAJOR R. OWENS, New York
JOHN M. McHUGH, New York EDOLPHUS TOWNS, New York
JOHN L. MICA, Florida PAUL E. KANJORSKI, Pennsylvania
MARK E. SOUDER, Indiana CAROLYN B. MALONEY, New York
STEVEN C. LaTOURETTE, Ohio ELIJAH E. CUMMINGS, Maryland
DOUG OSE, California DENNIS J. KUCINICH, Ohio
RON LEWIS, Kentucky DANNY K. DAVIS, Illinois
JO ANN DAVIS, Virginia JOHN F. TIERNEY, Massachusetts
TODD RUSSELL PLATTS, Pennsylvania WM. LACY CLAY, Missouri
CHRIS CANNON, Utah DIANE E. WATSON, California
ADAM H. PUTNAM, Florida STEPHEN F. LYNCH, Massachusetts
EDWARD L. SCHROCK, Virginia CHRIS VAN HOLLEN, Maryland
JOHN J. DUNCAN, Jr., Tennessee LINDA T. SANCHEZ, California
JOHN SULLIVAN, Oklahoma C.A. ``DUTCH'' RUPPERSBERGER,
NATHAN DEAL, Georgia Maryland
CANDICE S. MILLER, Michigan ELEANOR HOLMES NORTON, District of
TIM MURPHY, Pennsylvania Columbia
MICHAEL R. TURNER, Ohio JIM COOPER, Tennessee
JOHN R. CARTER, Texas CHRIS BELL, Texas
WILLIAM J. JANKLOW, South Dakota ------
MARSHA BLACKBURN, Tennessee BERNARD SANDERS, Vermont
(Independent)
Peter Sirh, Staff Director
Melissa Wojciak, Deputy Staff Director
Randy Kaplan, Senior Counsel/Parliamentarian
Teresa Austin, Chief Clerk
Philip M. Schiliro, Minority Staff Director
Subcommittee on Criminal Justice, Drug Policy and Human Resources
MARK E. SOUDER, Indiana, Chairman
NATHAN DEAL, Georgia ELIJAH E. CUMMINGS, Maryland
JOHN M. McHUGH, New York DANNY K. DAVIS, Illinois
JOHN L. MICA, Florida WM. LACY CLAY, Missouri
DOUG OSE, California LINDA T. SANCHEZ, California
JO ANN DAVIS, Virginia C.A. ``DUTCH'' RUPPERSBERGER,
EDWARD L. SCHROCK, Virginia Maryland
JOHN R. CARTER, Texas ELEANOR HOLMES NORTON, District of
MARSHA BLACKBURN, Tennessee Columbia
CHRIS BELL, Texas
Ex Officio
TOM DAVIS, Virginia HENRY A. WAXMAN, California
Christopher Donesa, Staff Director
Nicholas Coleman, Professional Staff Member
Nicole Garrett, Clerk
Julian A. Haywood, Minority Counsel
C O N T E N T S
----------
Page
Hearing held on February 27, 2003................................ 1
Statement of:
Boyer-Patrick, Jude, M.D., M.P.H., Hagerstown, MD............ 67
Walters, John P., Director, Office of National Drug Control
Policy, accompanied by Andrea Barthwell, Deputy Director
for Demand Reduction, Office of National Drug Control
Policy; and Charles G. Curie, Administrator, Substance
Abuse and Mental Health Services Administration............ 23
Letters, statements, etc., submitted for the record by:
Boyer-Patrick, Jude, M.D., M.P.H., Hagerstown, MD, prepared
statement of............................................... 70
Clay, Hon. Wm. Lacy, a Representative in Congress from the
State of Missouri, prepared statement of................... 22
Cummings, Hon. Elijah E., a Representative in Congress from
the State of Maryland, prepared statement of............... 8
Curie, Charles G., Administrator, Substance Abuse and Mental
Health Services Administration, prepared statement of...... 40
Davis, Hon. Thomas M., a Representative in Congress from the
State of Virginia, prepared statement of................... 16
Ose, Hon. Doug, a Representative in Congress from the State
of California, prepared statement of....................... 83
Ruppersberger, Hon. C.A. Dutch, a Representative in Congress
from the State of Maryland, prepared statement of.......... 85
Souder, Hon. Mark E., a Representative in Congress from the
State of Indiana, prepared statement of.................... 3
Walters, John P., Director, Office of National Drug Control
Policy, prepared statement of.............................. 28
RECOVERY NOW INITIATIVE
----------
THURSDAY, FEBRUARY 27, 2003
House of Representatives,
Subcommittee on Criminal Justice, Drug Policy and
Human Resources,
Committee on Government Reform,
Washington, DC.
The subcommittee met, pursuant to notice, at 10:07 a.m., in
room 2154, Rayburn House Office Building, Hon. Mark E. Souder
(chairman of the subcommittee) presiding.
Present: Representatives Souder, Davis of Virginia, Mica,
Blackburn, Cummings, Davis of Illinois, Bell and Ruppersberger.
Staff present: Christopher Donesa, staff director and chief
counsel; Nicholas Coleman and Elizabeth Meyer, professional
staff members; John Stanton, congressional fellow; Nicole
Garrett, clerk; Julian A. Haywood, minority counsel; Earley
Green, minority chief clerk; and Teresa Coufal, minority
assistant clerk.
Mr. Souder. Good morning, and welcome to all of you for the
session's first meeting of the 108th Congress. We have a full
agenda for this session, and I'm very much looking forward to
the opportunity to continue working on it with our
distinguished ranking member, the gentleman from Maryland, Mr.
Cummings.
I would also like to welcome Chairman Tom Davis of the full
committee to our hearing today and to thank him publicly for
the strong personal interest and support he has demonstrated
for the work of this subcommittee.
I would finally like to thank and specially recognize our
new vice chair, the gentleman from Georgia, Mr. Deal and all of
the new Members on both sides of the aisle.
The subcommittee will be most intensely focused in the
beginning of this Congress on the reauthorizing legislation for
the Office of National Drug Control Policy and its programs.
Next week we will begin a series of hearings on that
legislation. Our topic for today, however, is so important that
I thought it should be the natural first meeting for the
subcommittee.
Today's hearing will consider the significant new drug
treatment initiative announced by President Bush in his State
of the Union Address. Drug treatment, specifically getting
treatment resources where they are needed, is one of the
cornerstones of our national drug control policy and strategy
and must be a prominent part of any sensible drug policy.
The necessary emphasis on law enforcement and homeland
security issues during the last Congress prevented the
subcommittee from addressing treatment issues to the extent
they deserved. So I particularly wanted to begin with treatment
at the center of our agenda today.
The President's initiative is a substantial, innovative and
compassionate step forward. I commend his personal interest and
support in emphasizing drug treatment as a priority item in his
domestic agenda. His proposal will take a big step forward to
make drug treatment fully available in the United States.
Perhaps just as importantly, however, it will also break new
ground by taking steps toward greater availability,
accountability and innovation in the treatment choices
available to help addicted Americans get well.
The President's initiative would provide $600 million over
the next 3 years to supplement existing treatment programs.
That amount of money is intended to pay for drug treatment for
most Americans who now want it but can't get it, many of whom
can't afford the cost of treatment and don't have the insurance
that covers it. It could help up to 100,000 more users get
treatment. The program also has enormous potential to open up
Federal assistance to a much broader range of treatment
providers than are used today.
Through the use of vouchers the initiative will support and
encourage variety and choice in treatment and could open up and
support a significant number of new options for drug users to
get treatment. Finally, the emphasis on accountability should
help us make significant progress in the most difficult issues
of drug treatment policy, finding and encouraging programs that
truly work to help and heal the addicted as well as ensuring a
meaningful and effective return on taxpayer dollars spent on
treatment.
I am pleased to welcome today's excellent witnesses for the
first public hearing and detailed discussion of this important
Presidential initiative. From the Office of National Drug
Control Policy we are joined by Director John Walters, who has
enthusiastically and energetically worked to outline and
develop the program. From the Substance Abuse and Mental Health
Services Administration, we are joined by the Administrator, my
fellow Hoosier, Charles Curie. Thank you both for your
leadership. We will later be joined by Dr. Jude Boyer-Patrick,
who has been a leading treatment professional in the State of
Maryland, to receive her insights.
It is a real pleasure to have all of you here today, and
the subcommittee looks forward to discussing the initiative
with you in depth.
[The prepared statement of Hon. Mark E. Souder follows:]
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Mr. Souder. I now yield to the ranking member, Mr.
Cummings.
Mr. Cummings. Thank you very much, Mr. Chairman. I am very
pleased that we are holding this hearing today. I'm glad that
the administration is taking a closer look and putting a
greater emphasis on treatment. Treatment is something that I
have preached about since I came here some 6\1/2\ years ago.
But before I go into my official statement Mr. Chairman,
I'd like to welcome to our subcommittee, Chris Bell from Texas,
Linda Sanchez from California, and certainly Dutch
Ruppersberger, my Maryland colleague, who has worked with me
prior to coming to the Congress in so many drug issues in the
Baltimore area, and our districts literally are connected to
each other. So I welcome him. I know that he will be a
tremendous asset to our committee.
Let me just say a few things right here. Mr. Chairman,
there is no simple issue that is more important to me than the
issue of drug treatment. Baltimore City, the city I represent
in Congress, has been devastated by recent epidemics of crack
cocaine and heroin addiction. There are some 65,000 people in
Baltimore addicted to illegal drugs, roughly a tenth of the
city's population, and these people desperately need treatment,
and effective treatment.
It is interesting to note while I applaud the President's
effort with regard to treatment, and I think it is absolutely
wonderful, I must tell you that when I returned to my district
the day after and talked--after the State of the Union and
folks were talking about the program in Baltimore, we saw it
from a whole different perspective. When the President talked
about helping 300,000 people, the people in my district said,
well, we've got 65,000 right in 1 of 435 districts--we've got
65,000 just in our district. And so that is not necessarily a
criticism, because one thing that I must say is the drug czar
are--Walters is making a study, marching toward the right
direction as opposed to staying still or going backward, and I
do appreciate that. I want to make that real clear, but I want
to put this in context, too.
Last year, Mr. Chairman, you convened a field hearing in
Baltimore at my request, and we heard testimony concerning the
results of a ground-breaking study entitled Steps to Success:
The Baltimore Drug and Alcohol Treatment Outcome Study.
Commissioned by the Baltimore Substance Abuse Systems, Inc.,
and conducted by the University of Maryland, Johns Hopkins
University and Morgan State University, the study examined
nearly 1,000 treatment participants in 16 licensed, publicly
funded treatment programs. The findings indicate a marked
reduction in drug and alcohol use, criminal conduct, risky
health behaviors and depression among individuals who
voluntarily entered publicly funded outpatient drug and alcohol
treatment programs in Baltimore City.
In the judgment of the Baltimore City Health Commissioner
Peter Beilenson, Steps to Success proved conclusively that drug
treatment is effective in Baltimore City. The study remains the
largest, most comprehensive and most thoroughly documented
study of its kind to focus on a single city. The Baltimore
study's findings reinforce those of other drug treatment
studies, including a report by the Institute of Medicine which
found that, ``an extended abstinence, even if punctuated by
slips and short relapses, is beneficial in itself and may serve
as a critical intermediate step toward lifetime abstinence and
recovery.''
In announcing the National Drug Control Strategy and drug
control budget last year, President Bush and the Office of
National Drug Control Policy Director John Walters expressed a
strong commitment to, ``healing American's drug users,''
pledging an additional $1.6 billion in drug treatment funding
over 5 years.
For this the administration received high praise from
treatment experts and advocates, and deservedly so. There has
not always been strong bipartisan support for funding drug
treatment. It seems, thankfully, that we are finally beyond
questioning the value of treatment and firmly on the road to
funding recovery. The question that remains is how
aggressively, and what is the most effective and efficient
means of reaching people in need.
In his recent State of the Union Address, President Bush
proposed a new drug treatment initiative called Recovery Now to
be funded with $600 million over the next 3 years. The
proposal's reliance on State-issued vouchers is a sharp
departure from the way the Federal Government has funded drug
treatment through the Substance Abuse and Mental Health
Services Administration since SAMHSA's creation in 1992. For 10
years the vast majority of Federal funding for drug treatment
has been allocated to States by way of a population-based
formula under the substance abuse prevention and treatment
block grant.
This year the drug treatment system is undergoing
significant change as the block grant transitions to a
performance partnership grant. This change is already altering
the relationship between the States and SAMHSA, with a goal of
providing greater flexibility to States in exchange for greater
accountability.
Among other changes, States are in the process of upgrading
their computer systems in order to collect and convey
additional data on program performance, and I applaud that.
Like the existing Targeted Capacity Expansion Grant
designed to help States respond quickly to emerging treatment
needs, Recovery Now will operate parallel to the substance
abuse partnership performance grant. The initiative will
require Governors to submit proposals for State-run voucher
systems that will operate subject to Federal guidelines that
are presently under development. A request for applications
will issue later this year.
As we will hear from the administration witnesses, Director
Walters, SAMHSA Administrator, Charles Curie, Recovery Now is
intended to give people in need of drug treatment a broader
array of treatment options by expanding the network of
providers who will be eligible to receive Federal funding for
providing treatment services. As we all observed, the President
took pains in his State of the Union Address to emphasize that
pervasively sectarian faith-based organizations would be part
of the expanded provider network. The standards to which these
groups will be subject is an important issue for Members like
myself who are deeply concerned about the implications
permitting the use of Federal funds by programs that would
discriminate on the basis of religion against employees or
people seeking treatment or both. I have often said that we
cannot allow our tax dollars to be used to discriminate against
us.
The Recovery Now initiative is also designed to increase
provider accountability by making reimbursement to providers
contingent upon their demonstrated effectiveness, determined
according to a set of evidence-based outcome measures. I agree
with that. I think that is very good. This is a novel approach
in the public health field. It aims to create healthy
competition among providers to deliver the most effective
treatment.
As we explore all of this new ground, I'm delighted that
we'll have the outside perspective of an experienced medical
practitioner and researcher in the field of child and
adolescent mental health and substance abuse. Dr. Jude Boyer-
Patrick of Brooklane Health Services in Hagerstown, MD, is a
woman of deep faith, an addition in mental health specialists,
and a shaper of public policy through her service on Maryland's
Drug and Alcohol Council and the Maryland Drug Treatment Task
Force. She will offer her informed insight concerning a variety
of outstanding concerns relating to Recovery Now, including how
State standards for care, licensing and certification will fare
under the proposal, State administrative costs and possible
obstacles to implementation, standards that will be applicable
to faith-based treatment providers, challenges to providers
posed by the voucher reimbursement system, protecting the
existing substance abuse grant from erosion, and ensuring the
maximum participation by the States under initiative--under the
initiative's competitive grant structure.
And I'm also pleased, too, that Dr. Andrea Barthwell, the
Deputy Director for Demand Reduction, is with us today. She,
working with the drug czar--that has been most cooperative with
our office. And let me finally say this, too, to the drug czar,
Mr. Chairman. The drug czar has been extremely responsive to
the needs of the Seventh Congressional District of Maryland. He
has paid several visits to our district already. He attended
the funeral of seven people--of six people and then seven.
There was a seventh later on--who died as a result of a fire,
where drug salespersons fire-bombed a house and literally
burned up six members of this household who had been
cooperating with police. And later--it was a mother and five
children--he attended that funeral and made one of the most
moving comments that I have ever heard in my life by anybody on
anything.
He has been there for us, and he has worked very closely
with us trying to bring some remedies in a short period of time
to our district, and so I do applaud you, drug czar. I always
call you the drug czar. I'm trying to fix it up so it sounds
real nice in public, but I thank you.
And so, Mr. Chairman, again, I am glad that we're holding
this hearing. I think that this is a step in the right
direction, and I also want to thank Chairman Davis for his
interest in this issue. And I think just having him as the
chairman of our overall committee heightens the visibility and
the opportunities that we will have to explore all of these new
issues and new programs so that, again, we can use our tax
dollars in a most effective and efficient manner.
[The prepared statement of Hon. Elijah E. Cummings
follows:]
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Mr. Souder. Now I'd like to yield to the chairman of the
full Government Reform Committee, Mr. Tom Davis of Virginia.
Mr. Davis of Virginia. Mr. Souder, thank you, and thank you
for holding your hearings and your leadership. And I thank my
friend from Maryland for his comments and for his leadership on
this issue as well.
This is not a partisan issue at all. This affects people,
Republicans, Democrats, inner city, wealthy, suburbs, rural
areas. It is a tremendous responsibility for this committee and
for the drug czar, for lack of a better title, to undertake,
and we want to give you the tools.
And over the past year drug use among young Americans has
been on the decline, I think, due in large part to our joint
administration, congressional--our joint work and our
substantial drug prevention efforts, but when it comes to
addressing the complex dilemma of drug addiction, prevention is
only one part of the equation. Treatment of substance abuse, as
my friends have said, and addiction is also essential to the
goal of decreasing the number of users.
Because addiction has so many dimensions and disrupts
multiple aspects of an individual's life, treatment is never
easy. Drug users need a support system of family, friends and
institutions to help guide them to treatment and recovery.
I know firsthand the consequences that substance abuse can
have on a family. My father was a career alcoholic, he actually
served two tours in the State prison system in Virginia for
alcohol-related offenses. It is not just the victim. The whole
family struggles with these issues, and it affects an extended
family as well.
The President's 2003 National Drug Control Strategy
highlights the importance of healing America's drug users and
getting treatment resources where they are needed most. I
appreciate John Walters and Charlie Curie of the Substance
Abuse and Mental Health Services Administration for being here
this morning to discuss the President's drug treatment
initiative, an important outside-the-box element of the
President's strategy.
According to the Office of National Drug Control Policy,
roughly 6 million Americans are in need of drug treatment, but
a large number of these users fail to recognize their need for
treatment or don't have access to treatment programs. So the
administration has proposed a significant increase in drug
treatment funding that will expand access to substance abuse
treatment in communities across America.
The new treatment program would devote $600 million over 3
years for a new initiative to fight drug addiction. It aims to
expand access to treatment centers for an estimated 100,000
alcohol and drug abusers annually through a voucher system that
will let the government monitor where the dollars are being
spent. Too many Americans in search of treatment simply cannot
get it. As proposed, the program would give people vouchers to
seek drug rehabilitation treatment centers of their choice,
including community and faith-based treatment organizations.
Just a note on faith-based organizations. I will never
forget as a member of the county board in Fairfax having the
Salvation Army come forward with a drug and alcohol
rehabilitation center adjacent to some residential
neighborhoods, and a band of associations came out and fought
it, but we prevailed. We zoned it. It came in and has over 125
individuals at a time it can take. And I was there after it was
built, and I was there the first year when people came up and
gave testimony for a year without drugs and alcohol. There are
2- and 3-year pins, and the interesting thing about the faith-
based is they take not just the medical side of it, but they
look at the heart, they look at the soul to heal the entire
person.
These can be successful programs as well. I think sometimes
we fail to utilize these as well. I'm happy to see that is a
part of this program, because in many cases that is the answer
is changing the whole person from the inside.
As proposed, the program gives people vouchers to seek drug
rehabilitation treatment centers of their choice. Obviously
there is much more to this complex proposal than I've outlined.
I'll leave it up to our witnesses this morning to elaborate on
that initiative and provide all the details, but with let me
make a couple more points.
First, we all know that drugs affect people from all walks
of life, and addiction does not discriminate. I believe that
making funding available through the voucher program to a wide
range of providers, including faith- and community-based
programs, schools, health care providers, employers and law
enforcement agencies, better ensures the substance abusers will
be matched with a treatment program appropriate for them. The
plan, plain and simple, broadens the network of treatment
providers.
Second, there is much about the proposal's details that I
like on the face. It relies heavily on collaboration with the
States. It fosters competition among providers. It promises
flexibility in terms of the systems developing in individual
States, and it mandates strict oversight of programs to ensure
their effectiveness.
Finally, I've just returned from a trip to Colombia with
Chairman Souder. We'll be going back before long because the
battle going on there against narcoterrorism is our battle as
well, but it is clear to me as we continue to wage war on the
supply side of the drug equation, we need to reaffirm our
commitment to address the demand side as well.
Again, Chairman Souder, I thank you for organizing today's
important hearing to review the President's treatment
initiative. This will be the first in a series of hearings
planned to evaluate all of the components of the President's
2003 drug strategy. I look forward to the input from my
colleagues on the other side as well. Many of them have worked
in their own districts on this program, and it is important to
them as well. And we can work on this in a bipartisan way. I
think we can come up with a good result. I look forward to
hearing the testimony this morning from the officials
responsible for developing and implementing the program. Thank
you.
Mr. Souder. I thank the Chairman.
[The prepared statement of Hon. Thomas M. Davis follows:]
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Mr. Souder. Before yielding to Mr. Davis, I want to
elaborate. Both Mr. Cummings and Mr. Davis and I have made--
actually all three of us made references to some of what the
committee is going to be doing, and as I said, our primary
focus, because we're trying to move a bill through the full
committee and the subcommittee in a reasonably expeditious
manner for the ONDCP reauthorization, we're focusing on more
particular elements of the national ad campaign, the HIDTAs.
And so over the next few months, we'll continue our work on the
borders, which are critical, but part of our oversight.
In the faith-based component, this subcommittee also has
oversight over all faith-based programs, not just on the
treatment, and today we're focusing on treatment in general,
which would include the vouchers, but not zeroing in on faith-
based, and I appreciate working with the minority. I have made
a commitment we will have a separate hearing talking about that
issue alone inside the treatment question, in addition to
basically 2 years of looking at the range of faith-based. We're
going to have disagreements on how much government funding and
which type of government funding should go in, but we're going
to look at the other parts of the faith-based initiatives as
well, which would include a much broader program where we may
have wide agreement, as well as the more narrow controversial
part, which is when government funds are involved in the
treatment program.
And then as far as the tragedy with the Dawson family in
Baltimore, we've made a commitment that later this spring we'll
be doing a hearing there to look at how the government should
be providing protection for those who work with the government
who are threatened, and they should not be out there to be
terrorized by the dealers and their networks, and it is a
broader question in a policy way of how we're trying to protect
those who are working at the grassroots level. And I definitely
appreciate the leadership of the ranking member with that.
With that, I'd like to yield to the long-time acting member
of this subcommittee Mr. Davis of Illinois if he has any
opening statement.
Mr. Davis of Illinois. Thank you very much, Mr. Chairman.
Let me just, first of all, commend you and the ranking member,
Mr. Cummings, for the aggressive manner in which you have
approached the work of this committee. I've been very pleased
to travel with you to Fort Wayne, IN, for a field hearing, and
I want to thank you for the hearing which you conducted at my
request in Chicago.
I also want to welcome the witnesses. It seems as though
the seventh number of districts must have some affinity for
Director Walters, I was pleased to visit with him and with you
at the Safer Foundation not very long ago where we had a
tremendous experience.
I also want to welcome Mr. Curie, and I definitely want to
welcome my neighbor, my friend and long-time associate Dr.
Andrea Barthwell, who has had firsthand hands-on experience
working on the ground with these issues and problems as a
practitioner with the Human Resources Development Institute and
other entities. And so, Dr. Barthwell, it is indeed a pleasure
to see you.
Very briefly, Mr. Chairman, let me just suggest that this
hearing is so important, and the work of this committee is so
important. We all know that much of the crime, much of the
prison population explosion, many of the problems associated
with reentry are all associated with drug use and abuse, and so
when we deal with the issue of reducing the presence of drug
use and abuse in our society, we're dealing with needs that cut
across all races, all economic groups all parts of what makes
this Nation what it is.
I'm pleased to see that prevention, treatment and reduction
are all a part of a strategy, and I think all of those
components must be effectively used.
We've had some discussion about the utilization of the
faith-based approach, and as one who is a strong component--
strong proponent, I've seen faith-based programs work, I've
seen people involved in them. My district has a serious drug
problem because of its poverty and because of its location and
because of where it is, Chicago, IL, in the heart of the
Midwest.
Programs can work, do work. I would make a strong plea that
we make every effort to eradicate any possibility of
discrimination that could possibly exist, and that we let an
idea that is really a great idea, a tremendous idea, let that
idea stand on its merits and let it work on its merits by
taking away any possibility that any person, because of their
religion, their religious thoughts, their religious beliefs,
could possibly not acquire the services and the benefits.
I look forward to discussion, I look forward to development
and implementation, and, again, I thank you, Mr. Chairman, and
appreciate all of the witnesses who have come to share.
Mr. Souder. Thank you, Mr. Davis.
Mr. Clay, do you have any opening remarks?
Mr. Clay. Thank you, Mr. Chairman. First I'd like to
acknowledge your foresight for holding this important debate
concerning the President's recently announced antidrug
treatment program, the Recovery Now initiative. America needs
an effective drug treatment program that will work. Previous
efforts by law enforcement agencies have already proven that
drug eradication initiatives alone have not stopped the problem
of drug adduction, even in the best of scenarios.
Plain and simple, drug addiction should not be viewed as a
criminal problem, but rather, it should be perceived as a
medical challenge. The increase in human drug addiction is a
societal problem that is a challenge that transcends race,
class and financial standing.
The Recovery Now initiative is an ambitious step in the
right direction to alleviate the challenge of rampant drug
abuse in the 21st century.
And, Mr. Chairman, I ask unanimous consent to submit my
statement into the record.
Mr. Souder. Without objection, so ordered.
[The prepared statement of Hon. Wm. Lacy Clay follows:]
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Mr. Souder. I thank Mr. Clay for being here today, as well
as Congresswoman Blackburn from Tennessee and Congressman
Ruppersberger. We'll have many Members in and out this morning,
and I appreciate the patience of our witnesses.
Before proceeding, I would like to take care of a couple of
procedural matters. First, I ask unanimous consent that all
Members have 5 legislative days to submit written statements
and questions for the hearing record; that any answers to
written questions provided by the witnesses also be included in
the record. Without objection, so ordered.
Second, I ask unanimous consent that all exhibits,
documents and other materials referred to by Members or the
witnesses may be included in the hearing record; that all
Members be permitted to revise and extend their remarks, and
without objection, so ordered.
I would also like to ask the members of the committee and
the minority in particular, we didn't notice Dr. Andrea
Barthwell, who is going to be here to support the Director, but
in case she fields some questions, is it OK if I swear her in
at this time?
Mr. Cummings. Yes. I think that is a great idea. I think
you need a sign, too.
Mr. Souder. Without objection, we'll include you on the
first panel, because we didn't notice it in the committee. So
we need to go through that procedure.
If each of you could rise and raise your right hands, it is
the practice of this subcommittee as an oversight committee to
ask the witnesses to testify under oath. If you'll raise your
right hands, I'll administer the oath.
[Witnesses sworn.]
Mr. Souder. Let the record show that each of the witnesses
responded in the affirmative.
We'll now hear from Director Walters. We thank you first
for your leadership. We very much appreciate that, and I look
forward to hearing your testimony today.
STATEMENTS OF JOHN P. WALTERS, DIRECTOR, OFFICE OF NATIONAL
DRUG CONTROL POLICY, ACCOMPANIED BY ANDREA BARTHWELL, DEPUTY
DIRECTOR FOR DEMAND REDUCTION, OFFICE OF NATIONAL DRUG CONTROL
POLICY; AND CHARLES G. CURIE, ADMINISTRATOR, SUBSTANCE ABUSE
AND MENTAL HEALTH SERVICES ADMINISTRATION
Mr. Walters. Thank you. I'd like to thank Chairman Davis
for being here and for the conversations and the support we've
already had since he took the chairmanship. It has been a busy
time, and he carved out time not only to meet and talk at some
length with myself, but also, as he mentioned, travelled to
Colombia and began looking at some of these programs and the
crush on business.
I'd also like to thank you, Chairman Souder, for the
tireless work you've already done on this. We have personally
travelled together through a number of countries in this
hemisphere, including Bolivia, Colombia, Canada, as well as
worked extensively on this issue, and I look forward to working
with you again and thank you for your dedication here.
I'd also like to thank Ranking Member Cummings for his kind
words. As he knows, and I've said to him privately, it has been
one of the pleasures of this job working with him on some of
the problems in Baltimore. We know we don't make people well
sitting in our offices and making the policy. We've tried to be
more proactive, because I know the reality that Baltimore faces
of no city, I believe, in the history of this country has
suffered more from the problem of substance abuse and addiction
than Baltimore, and our goal is to make it the best example of
a city that comes back. And that is not something we do alone,
but it is part of what our partnership requires.
Also Mr. Davis, it was my pleasure to meet with you in
Chicago, and he spent time with us at the Safer Foundation in
part of an effort to also try to work with a variety of
providers and to learn what goes on in the country as we shape
policy and program.
So, thank you all. You've all been very active, and I look
forward to working with other members of the committee as this
process goes on.
If it is acceptable to the committee, I'd like to ask that
my written statement be included in the record, and I'll just
summarize some of the things and then proceed as we get to
questions with the topics you think are most appropriate.
We're here as a next stage to ask your help in allowing us
to implement the ambitious program outlined or proposed by the
President in the State of the Union. We believe that the
centerpiece, as your comments have indicated, to what we need
to do about the problems of drugs is to treat more people who
have dependency. It is not the only thing that we do, but it is
a crucial part of what we're going to do if we're going to make
this problem smaller.
I'm pleased to be joined by Administrator Curie, who we've
worked with tirelessly, and by Dr. Barthwell, whose expertise
and whose background as former president of the American
Society of Addiction Medicine. She has been willing to
generously give of her talents and time. I could not do what I
do without her help, and I would like to publicly say that and
thank her, and for the tireless work that she has given to this
effort.
The initiative that we have proposed in expanding treatment
complements the other Federal support to treatment, but it does
provide a new way to direct those dollars. We've consulted with
some of the foremost treatment and professional associations
throughout the country throughout the last year, and we've
consulted with them since the announcement of this proposal.
We've been gratified by the endorsements we've received
from individuals and organizations such as Lawrence Brown, the
president of the American Society of Addiction Medicine, the
society that Dr. Barthwell was president of previously; Mark
Parrino, president of the American Association for the
Treatment of Opioid Dependence; Linda Hay Crawford, executive
director of Therapeutic Communities of America; Arthur Dean,
chairman of the Community Antidrug Coalitions of America;
Melody Heaps of National Treatment Accountability for Safer
Communities [TASC]; Phoenix House, the Nation's largest
nonprofit substance abuse agency; National Black Alcoholism and
Addictions Council; the National Asian Pacific Americans
Families Against Substance Abuse; Pride Youth Programs, the
largest youth prevention organization; the National Association
of Drug Corps Professionals; and Alcohol and Drug Problem
Association of America. These are some of the foremost groups
in the country. We've benefited from their expertise and
consultation, and we appreciate their support as these efforts
go on.
We've made clear, and you all agree, we have to push back
against the problem of illegal drugs. We ought not to
surrender. We ought not to be cynical. We ought to do our job
to make this a smaller problem in America. The President
forthrightly set the national goal of a 10 percent reduction in
2 years and a 25 percent reduction in 5 years of the number of
Americans who use drugs. There are hopeful signs that show that
we're making progress.
The Monitoring the Future Survey of 8th-, 10th- and 12th-
graders released in December showed that last year we had drops
of 11 percent for 8th graders and 8.4 percent and 1.2 percent
respectively for the 8th, 10th and 12th grade populations.
We've had other surveys that indicate that drug use may be
declining in different rates shown by different surveys. The
Pride Survey of School Children found a 14.3 percent decline in
past month's drug use by junior high school students. This is
an important, encouraging momentum, but we have to follow
through. We're not where we want to be. We want to capitalize;
we want to accelerate on this.
What treatment means for our policies can be seen, I think,
in the National Drug Control Strategy, because it is the center
of three pillars. The first is stopping drug use before it
starts through education and community action. The second, as
Congressman Cummings mentioned, is healing America's drug users
by getting treatment resources where they are needed and
helping people successfully get into recovery and stay there.
Third, we are dedicated to disrupting the market that is the
drug trade, the poison that is marketed to too many Americans
and infects, of course, peoples throughout the world.
These strategic pillars are designed to work together to
give balance and to give a magnitude of power that neither one
of them alone would provide. When substance abuse treatment
leads to recovery, we advance our goals. The demand for drugs
goes down. The economic basis for the drug trade is damaged.
Prevention is strengthened because drug users are the carriers
of the disease of drug addiction. Most importantly, we save
lives, of those who are users, of those around users, and of
the communities which use affects.
The scope of the need for treatment that we affect is
outlined in the National Drug Control Strategy, and some of you
in your opening remarks have alluded to his. We have identified
roughly 6.1 million individuals needing treatment because of
the nature of their drug use, abuse or dependence; 76 percent,
however, have yet to recognize that need. That is 4.7 million
people that are in a form of what we call the denial gap.
Seventeen percent did receive treatment at some time during the
year, previous year's survey, in a specialty facility. That's
1.1 million people. Five percent need treatment and recognize
the fact, but nevertheless did not seek it, over a quarter of a
million people, and 2 percent, approximately 100,000 persons,
sought treatment, but did not receive it for their substance
abuse or dependence.
This latter group have demonstrated an immediate need for
services and a willingness to seek help. They deserve a
response to their courageous efforts to change. This response
is a central feature of the President's voucher initiative.
That is not to say we do not intend to strengthen efforts to
reach the other people in these categories, but we have people
who are coming forward for help and are not being helped today.
We'd like to start with that population in more cases and more
places.
The vouchers provide immediate impact and access to
treatment. As we've tried to define the program, the $200
million a year for each year, fiscal years 2004, 2005 and 2006,
complements the nearly $3.6 billion budget for substance abuse
treatment, a total increase of $271 million over the
President's fiscal year 2003 request.
As intended with those without recourse, the private
insurance or other Federal support such as Medicaid can be used
for substance abuse, dependency and abuse, including alcohol.
It builds on current State incentive grants, the Substance
Abuse Prevention and Treatment Block Grant, and the Targeted
Capacity Expansion Grants, as some of you mentioned.
The initiative, we hope, will expand treatment capacity.
The initiative builds on community outreach to overcome the
denial gap. It will serve more people more efficiently and will
increase effective treatment. A broader base of treatment
providers, proprietary, nonprofit, government-run,
nongovernment-run providers, we hope, will be encouraged to
enter the system. Existing treatment providers will be held to
higher expectations of performance, and expanded capacity will
be targeted to actual local need.
The so-called IMD exclusion that has prevented some
providers to provide residential care in larger institutions
would not hinder this program. The so-called IMD exclusion
would be lifted. The initiative would not exclude those
providers who offer resources tied to faith as part of the
process of recovery, as some of you have mentioned.
The current medical and mental health providers have an
opportunity to offer substance abuse services that would be
funded if they are effective. The initiative builds on a system
of professional assessment and referral with the provision of
vouchers flexible enough to meet individual need. Whenever a
person receives medical care, they can enter the system.
Additional community resources can play a role with employers,
family members, schools and houses of worship. We have many
people who need assessment who are not facing up to their need,
and we know when we create gaps, people fall through those
gaps. We want the assessment, the referral and the resources to
be tied more closely together.
The initiative uses the instrument of choice to broaden and
strengthen the treatment system. It brings target treatment
resources into line with actual community need, enables a
better match of specific specialty service need with treatment
modality. It provides flexible services, offering a continuum
of care from early intervention to detox to in-patient
residential services depending on the need.
The initiative insists on performance outcomes and rewards
efficient services that deliver on the promise of recovery.
Standards will be built into the system when States compete for
the grants, and the standards are required to measure effective
outcomes built on a competitive State grant system with State
oversight for eligibility to provide services; insists on
monitoring and reporting of outcomes for continued
participation.
Evidence-based and standardized treatment assessment and
referral will be a part of this program, and a variety of
measures can be used to evaluate effectiveness. Criteria must
include abstinence from substance use as one of its factors.
We will work with the States to adapt these requirements
and needs to State situations, and we will allow the program to
be deployed with maximum, hopefully, ability to use the
resources and capability of individuals, States and communities
as well as their needs.
Because the initiative represents new money, States have an
incentive to meet our standards and improve their treatment
systems, we believe, to a greater extent. The initiative brings
accountability to substance abuse treatments. We not only want
to reach those who have not before had access to treatment, we
want to insist on those who receive treatment actually achieve
recovery in more cases.
In 2002, nearly 1.2 million individuals received treatment
services, but too often they did not achieve full recovery. The
treatment system must be strengthened, with effectiveness being
the key requirement, and also, when they fail, to get them back
into treatment, into another form that is more effective to
them. We will reward what works with this system. We'll have a
system that expects to make a difference, and the voucher is a
tool for shaping and improving that system, we believe.
The key to accountability is a mechanism of payment. Full
reimbursement follows from demonstrated successes is what we
are proposing as a guideline as we work out the specifics of
this program.
Let me close by saying that healing America's drug users is
the responsibility of a compassionate Nation. I have not met a
single Member of Congress or a member of the public that
doesn't believe that, and too many people are disheartened by
the number of people who don't get help and are not healed. We
insist on doing better, and the President has charged us and
the administration with being more aggressive and more direct
in meeting that cry for better results as a Nation for those
who are suffering.
Providing effective resources for recovery saves lives and
strengthens our country. When people accept their
responsibility to change, we can meet them and help free people
from addiction. This initiative is an important new tool in
meeting these challenges, and I appreciate the opportunity to
talk to you today about it and to work with you in helping more
people integrate back into the opportunity that we all want for
all Americans. Thank you very much.
Mr. Souder. Thank you very much.
[The prepared statement of Mr. Walters follows:]
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Mr. Souder. I'd like to now welcome my long-time friend,
fellow Hoosier, Charles Curie. Everything he says that's right
today is because he was born in Indiana. Everything he says
that's wrong is because he lived in Pennsylvania too long.
Welcome, Mr. Curie.
Mr. Curie. Thank you, Mr. Chairman. I appreciate the
opportunity to be here. I appreciate, too, the opportunity to,
again, see my good friend and fellow Hoosier. I think last time
I had an opportunity to meet with Ranking Member Cummings, as
well as Mr. Davis was at the field hearing in Fort Wayne, IN.
And I was back home in Indiana that day, and it was, I thought,
also a tremendous field hearing focusing on that intersect with
criminal justice which you emphasize today, which is a very
important part of all we do.
Also, Chairman Davis, it has been a privilege and pleasure
to speak with you beforehand, and appreciate your support, as
well as members of the subcommittee, Mr. Clay.
I would like to ask that my written testimony be submitted
as part of the record, and on behalf of Health and Human
Services Secretary Tommy Thompson, I'm very pleased to share
this opportunity with Director John Walters, with whom we have
forged a very strong relationship with and have appreciated
very much the partnership, the guidance and the direction and
the leadership that Director Walters has provided, as well as
the relationship with Dr. Andrea Barthwell. I've appreciated
that very much, and it has been, I think, a great collaboration
within the administration.
And it is a privilege to discuss President Bush's proposed
substance abuse treatment initiative today. This new initiative
continues to fulfill the President's promise to invest $1.6
billion new dollars in addiction treatment over 5 years. Of
that $1.6 billion he proposed in the State of the Union, $600
million over the next 3 years is for this initiative. The first
$200 million installment is included in the President's
proposed 2004 budget for the Substance Abuse and Mental Health
Services Administration [SAMHSA]. SAMHSA's statutory authority
for administering this program is provided under sections 501
and 509 of the Public Health Service Act.
SAMHSA's vision, a life in the community for everyone, is
clearly consistent with the President's substance abuse
treatment initiative. SAMHSA's vision is achieved by
accomplishing our mission, building resilience and facilitating
recovery. Working together with the States, local communities
and public and private sector providers, we work to ensure that
people with or at risk for mental or addictive disorders have
an opportunity for a fulfilling life, a fulfilling life that is
rich and rewarding and includes a job, a home and meaningful
relationships with family and friends.
To provide treatment services for people who have substance
abuse problems, SAMHSA currently funds, as has been mentioned,
the Substance Abuse Prevention and Treatment Block Grant and
Targeted Capacity Expansion Grants. The block grant with its
required maintenance of effort will continue to support and
maintain the basic treatment infrastructure which exists in
States throughout the country.
For fiscal year 2003, the block grant totals nearly $1.8
billion. Targeted Capacity Expansion Grants, which total
approximately $320 million for fiscal year 2003, are awarded to
State and local governments to address new and emerging
substance abuse trends and to respond with treatment capacity
before problems compound. This ensures us flexibility and gives
us agility to meet treatment needs in the most relevant way.
The President's new substance abuse treatment initiative
provides a third funding mechanism to expand substance abuse
treatment capacity. It will utilize vouchers for the purchase
of substance abuse treatment support services. Specifically, it
clearly enables us to accomplish several objectives that have
long been identified by those in the field, policymakers,
legislators, and the very people we serve, as critical to
moving the substance abuse treatment field forward.
The first objective is to recognize that there are many
pathways to recovery. For the first time individuals will be
empowered with the ability to choose a provider, whether
nonprofit, proprietary, community-based or faith-based, that
can best meet their needs. The very personal process of
recovery can include meeting a person's physical, mental,
emotional and spiritual needs. In particular for many
Americans, treatment services that build on spiritual resources
are critical to recovery. We must work to ensure that all
Americans are allowed a full range of treatment services,
including the transforming powers of faith. Denying these
resources for people who want to choose and need them denies
them the opportunity for recovery. Vouchers will allow recovery
to be pursued in an individualized manner, and, in other words,
we're able to realize the epitome of accountability, which is
consumer choice.
The second objective is to reward performance. The voucher
program will offer financial incentives to providers who
produce results. Outcomes that demonstrate patient successes,
including no drug or alcohol use, employment and no involvement
with the criminal justice system, will be used in determining
ultimate reimbursement. Never before have we been able to so
clearly recognize outcomes as part of the quality and
effectiveness equation.
Finally, the third objective is to increase capacity. The
new resources will expand access to treatment and the array of
services available. Vouchers can be used to pay for medical
detox; in-patient, out-patient treatment modalities;
residential services; peer support; relapse prevention; case
management and other services supporting recovery.
To implement the President's initiative, we plan to issue a
request for applications late this summer, early fall. The RFA
will be based on SAMHSA's State and Senate grant model and will
be awarded to Governors' offices. We believe the Governor is
key to ensuring a coordinated approach among various State
departments such as State drug and alcohol authorities, mental
health authorities, departments of education, child welfare,
Medicaid and criminal justice agencies. After all, each of
these arenas provide services to people with addictive
disorders.
We are working with the States, because they are our
primary resource for substance abuse treatment services. These
services are funded through State revenue and Federal programs,
including SAMHSA's block grant, Targeted Capacity Expansion
Grants and some Medicaid dollars. We want to ensure the new
voucher program is coordinated and integrated into these State-
operated programs.
We'll be working with multiple stakeholders, including
States, providers and national associations, to develop the
RFA. The RFA will include broad standards and consistent
performance expectations. Financial data will be used to
monitor costs and to ensure that funds will be used for
appropriate and intended purposes. Performance data will be
used to measure treatment success and ultimately to measure the
success of the voucher program.
We expect that successful applicants will establish the
following: Demonstrate a need based on data; present the most
feasible approaches consistent with the voucher program's
guiding principles; eligibility criteria for providers;
eligibility criteria for clients; criteria for matching clients
with appropriate treatment; standards costs/reimbursement for
treatment modalities.
Critically, States must use these funds to supplement and
not supplant current funding; therefore truly expanding
capacity.
We see the President's initiative as a unique opportunity
to bring profound change in the financing and delivery of
substance abuse treatment services. As the President said, our
Nation is blessed with recovery programs that do amazing work.
Now we must connect people in need with people who provide the
services. We look forward to working with you, the Congress,
our Federal, State and local partners to make this program
successful for the people we all serve. Thank you.
[The prepared statement of Mr. Curie follows:]
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Mr. Souder. Thank you both.
I'd like to start with a capacity question. Director
Walters in his statement talks about the utilization rate, in
that there is a deficit of those actively seeking of around
100,000. In your statement it says it is particularly
pronounced in areas for juveniles, services in rural areas,
needs of women and mothers, and those who suffer co-occurring
mental disorders.
And in Mr. Curie's statement, you did two things, and this
is the first question I have to try and reconcile with this,
and it gets directly to the heart of where the program is going
to go, because you said that at the end there that there is a--
that the Governors will have to show an increase in capacity,
but you also described the--that this will--the vouchers could
be used for medical detoxification, in-patient or outpatient
treatment, modalities, residential services, peer support,
relapse prevention, case management and other services
supporting recovery, not all of which is the first round of a
treatment.
So my first question is, is the 100,000 shortage of people
who are seeking people at the initial stages who can't get
that, or would that include relapse prevention and other types
of things?
Mr. Walters. Well, I can let my more expert colleagues
elaborate, but the 100,000 is not a census, so we have an
estimate based on a survey of the country that is a
statistically representative sample, but it doesn't have the
fine grain to kind of tell us precisely where that 100,000
people are, all their demographic characteristics, because of
the cost of having such an extensive survey.
Fortunately, however, the drug dependency, the drug problem
is too big, but it is not so big that you don't have to do
fairly intensive surveying to kind of find the demographics of
small subpopulations. We know from other data, though, that in
particular areas there are underserved populations of some of
those that you enumerated, and we have, as I think you alluded
to, the ironic situation or the tragic situation I guess is the
better way to put it, of surveys for the last 10 years of
capacity utilization of looking at, given the slots we have of
various kinds, how full are they on any given day, show that
roughly 20 to 25 percent are vacant on any given day. At the
same time, we have people who are on waiting lists. We are not
doing as efficient a job as we would like to do, and I think
most people would like to do, in matching need to services.
What the voucher does is you pay for the actual service you
get. So it would be more efficient, we believe, and we're
spreading it over the range of services, because in individual
areas, some of these things are going to be more of a priority
than others. But the remarks you cited from Mr. Curie are
reflective from what I've seen and I'm sure you've seen going
around the country. In many cases specialized services for
women or even single men, a smaller population, who have
dependent children--services are lacking. In many cases
juvenile services are lacking. Many times for adults there
aren't the different kinds of services and modalities that we
need. But what this would hopefully do is expand the number of
people who would offer services of different kinds by
responding to the need, and also get the people who have the
need directly with the resources to get the services when we
assess them as having the need. And I'll let anybody else
elaborate.
Mr. Curie. Thank you. In addition--and I agree with
Director Walters' answer completely--the 100,000 figure comes
from our household survey, data derived from that, and
basically individuals in the sample across the country who
responded to questions which would have indicated that they
have a drug and/or alcohol problem, and the added feature they
responded, they recognized they had a problem, and they have
tried to seek treatment, could not find it. It would be
anticipated that in that 100,000 would be a range of
individuals, perhaps first-time individuals reckoning with it
as well as individuals who have dealt with this before in their
life.
Mr. Souder. Thanks. My time is about up. I assume we will
have a second round. But it leads to a fundamental question
about the program. Is the goal to expand the services
predominantly, or is it to better target the services, or is it
to make the services more effective, all of which theoretically
could be done, but aren't necessarily overlapping goals? And we
may have to have some prioritization.
And also perhaps in a followup written response, I would
appreciate receiving some more particulars on, for example, the
services of rural areas. What I found when I was on the
children and family committee is that many don't service rural
areas very much, but the numbers are fairly small that would be
impacted. What you have to do when you have limited dollars is
to figure out when you're targeting subgroups, is that going to
be out of 100,000, is that 1,000 people, but it takes up x
amount of the budget versus a waiting list in Baltimore where
it may be higher?
Another variable that I would suggest that you have just
addressed in your response on the vouchers to some degree is
the mismatch between capacity, because as a casual observer I
would say if you have health insurance, and if you are more
wealthy or have a job, you are more likely to get drug
treatment. The problem is that mismatch in that the capacity
may not match, particularly your proposal that you referred to
in the testimony about going to residential centers with 12
beds, which may be able to be more at the grassroots level
which are not currently in the program.
But one additional thing for the record I would like to see
is that in the list, you didn't include prison population, and
you didn't address directly whether low-income and minority
groups are having a more difficult time. I assume that comes
partly under your targeted programs in SAMHSA. But if we don't
get back to it today, if you could respond to those in a
written way.
Mr. Cummings.
Mr. Cummings. Mr. Chairman, I just want to followup on
something that you just raised that I hadn't thought about. Mr.
Curie and Director Walters, when we talk about need-based on
data, rates of abuse and dependence, when you have an area like
Baltimore and Maryland, the State, we have a lot of people--we
have one of the highest prison populations in the country, and
a lot of those folks went in there because of drugs, and sadly
they come out still with a drug problem. Would that be part of
the determination--in other words, you have one area that's got
8,500 people coming out a year, and you have another area of--
where maybe only 500 people come out a year coming back into a
community, and you can show in the past that there has been a
drug--some kind of correlation--I don't just want to say that
because somebody comes out of the prison, they have a drug
problem--but do you see that as something that would be taken
into consideration, because that's a major issue?
Mr. Walters. Yes. In fact, Mr. Davis visited the Safer
Foundation that's helping to reintegrate people who are coming
out of jails and prisons, some of whom are also getting drug
treatment services at the site we visited as well as other
reintegration help. This is the kind of flexibility we would
like to build into the program to allow States to provide those
services where the need is and to prioritize them. We're not
saying that the whole system isn't working. You know this as
well as I do. We visited the center in Baltimore together.
There are people doing outstanding work and serving important
parts of the population. But there are gaps, and there are just
overall capacity problems. So we would like to work with States
and localities to both target where the needs they see are and
also optimize the opportunities they believe there are to
expand capacity. There may be a need that they don't think they
have yet got the resources for, so a first stage may be to try
to do some training or try to get more people capable of
meeting that need. We're not trying to say one size fits all
here, but this is still going to be a partnership with the
States.
Mr. Cummings. What we have here, Mr. Curie, is that we've
got two programs under SAMHSA, as I read your testimony, and
this adds a third tool to try to address this big problem. And
so do you see any way that now we have these two programs that
already are existing in competition in any way with regard to
this third program, and how will that--how do you see the
transition going in your department?
Mr. Curie. Excellent questions. Clearly one of the reasons
we have wanted to select and utilize the States in the process
of implementation of this program is States--is where drug and
alcohol programs are primarily implemented. They're responsible
for the block grant as well as both communities and States
Targeting Capacity Expansion Grants and leave these States as a
point of integration. So we want to avoid any sort of not
maximizing the funds or any sort of competition, but we want to
make sure all three major types of funding mechanisms are
aligned and are working together. And currently now, as
Director Walters indicated, for the criminal or justice
population there are dollars in various States from the block
grant that are working toward both in conjunction with drug
courts as well as reentry programs as well as we have Targeted
Capacity Expansion Grants that are targeted. We also have a
partnership with the Department of Justice with the major
reentry initiatives, and we see those continuing.
We obviously, as Director Walters indicated, would be
looking at States as they propose how they would use this
voucher program of how they would address a criminal justice
population. That's clearly not precluded. One caution is
obviously treatment within the prisons has historically been
the criminal justice department's responsibility. So we would
want to be careful there's not supplanting.
Mr. Cummings. I was talking about once they get out, you
can always project how many are going to come out.
Just to piggyback on something the chairman mentioned,
whenever I see anything like this, I try to think as a lawyer,
and I think about the counterarguments and how do we get
consensus. And I can imagine that someone who is from a small
rural area, for example, I have a lot of rural areas, would
have the concern that the chairman just raised--that, you know,
how do you make sure that when you have problems in those
areas, that the money just doesn't all go to the big areas?
Because, I mean, if we took a Baltimore City situation, and
that is just 1 out of 24 counties, by the way, in Maryland,
with 65,000 addicts, you know, if I am Congressman Souder, I
might say, oh, my God, is all the money just going to go to
that glaring problem as opposed to the problem that we saw in
Fort Wayne, which I don't think is as glaring, but for the
people that are affected, it is pretty bad.
So how do you all see that? I know you have your two
programs already, but about this program and making sure we
don't have a situation where--and I know this is sort of
arguing against my own self, but I want to make sure the
program happens, and I know how the Congress works. So how do
you assure that Fort Wayne gets its due also? And he hit on
this, and I don't know whether you had a chance to answer that.
Mr. Walters. Well, we are aware that this is a problem that
is not uniform, but also does not affect simply one area and
not another. The rural problem tends to be less intense, as you
indicated. There's no question the heart of this problem is in
major urban areas, but that is not to say methamphetamine or
heroin or cocaine don't exist in rural areas.
The real problem for treatment in rural areas is that if
you provide services on the basis of building a facility or
supporting a facility, sometimes in sparse areas--I was in New
Mexico a month ago meeting with Governor Richardson, and people
are coming hundreds of miles to try to get services. Well, if
you have a juvenile or an adult, to have them pull up stakes
and have them move, that creates enormous problems, as you can
imagine, or the cost of transportation.
What the voucher would do, instead of trying to build them
and make the people come to the services, it would provide a
mechanism to local health clinics, local physicians, local
institutions could add more easily the services closer to the
people. It won't completely solve everything. And I think we
are interested in showing how this mechanism can work in rural
areas as well.
So we would want to look at and we will have to write the
regulations in a way that does recognize that is a need we look
at specifically, so we don't just say it's sheer numbers, so
that concentrations of populations would dominate all the
money. I have to go where the concentrations of need are as
well.
So I would not want to mislead you. And you know we are
going to end up driving this money to large urban areas because
that is what we have to do now. But I do think it is important
to say that we are not neglecting--I don't know of another tool
that would more effectively solve the problem of access in
rural areas than this program.
Mr. Curie. I would just add that clearly, the standards in
the RFA we issue would be looking to States to demonstrate how
they would assure that they're going to be addressing hard-to-
reach areas, and if the vouchers are there, it also provides
incentives for services that perhaps had not been there before.
Mr. Souder. The challenge is how to build certain
flexibilities, much like in heavily rural Appalachia. You
simply can't have the same size hospitals and clinics in every
single place in the United States.
Dr. Barthwell.
Dr. Barthwell. I just wanted to add that we've heard this
figure, 65,000 addicts in Baltimore who on any given date, need
treatment, and there has been a critical rule of thumb that has
been followed for some time, and it's borne out over years that
at any given time, on any given day, only about 15 percent of
people who have chronic severe debilitating forms of addiction
are seeking assistance for that. That is based on a number of
things: their own belief in their potential to recover, their
own belief in their ability to get help, the way in which
people around them reinforce their desire to change, whether
people put pressure on them to take action for the behaviors
that are being observed, and the cultural conversation about
addiction and nondependent use.
So if we were to look at that 65,000 people that need help
but are not seeking help or not able to get help, they would
distill to 9,750 who today would feel as if they should go
somewhere and seek help. And there's a lot of consistency with
figures in the National Household Survey. We're already
treating about 17 percent. Two percent said they went out at
some point during the year and sought treatment, but didn't get
it. So this program is going to extend that figure to about 19
percent. So we're doing a little bit better than we have done.
We also expect in our office to increase the pressure to
change the cultural conversation so that more people recognize
that they have a problem and develop a desire to change and are
compelled by the people around them to go out and seek
treatment. So we think that this President's treatment
initiative is going to address the 2 percent that went out and
sought help and didn't get it, but we fully expect if we can
continue to change the cultural conversation about drugs in
America, that number of people who feel as if they need help on
any given day is going to go beyond that 19 percent, and we
should prepare for having people seek treatment earlier so that
they are not experiencing chronic severe debilitating forms of
disease. They're getting off that treadmill much earlier than
they have been.
Mr. Souder. Chairman Davis.
Mr. Davis of Virginia. Thank you very much.
Accountability is an issue that's been discussed here. It's
the mainstay of the program. In your testimony you both have
stressed this will be outcome-based programs; that, in short,
the Federal dollars will not go to programs that don't show
demonstrable results. In connection with this, just a few
questions. How do you ensure that the results will be
effective? Will you test users? What happens to a provider that
isn't effective? What's the time period for measuring?
Mr. Walters. We talked about the general principles because
we haven't written all the regulations and the specifics yet,
but these are the general principles we have in mind. Once the
person comes in, is assessed, is referred to a treatment
provider, gets the services, after the services are completed
as decided by the provider, that there's a postservice
assessment. We can talk about how long afterwards or what the
full ramifications are.
We care that a component of that assessment is whether or
not the person receiving the services is abstinent. As Mr.
Curie said in his testimony, we can look at involvement with
the criminal justice system; other kinds of issues of
stability, like employment and others, and we probably should,
because for some varying degrees of severity of the clients
that you take in, you can expect varying degrees of
complications and relapse.
But we do not want to send the message that the system is a
revolving-door system. We do want to send the message that the
system is one built on a premise that while we say we believe
in it, we don't believe we can make people well categorically.
Sometimes when you talk to people, they won't say this in the
open. They will say, well, what we really need to do is be a
little more hard-headed. There is a category of user out there
that we can't help, and we ought to be more efficient in
resources by trying to identify that hard-core category and
move resources to those outside the hard-core category.
We, in the strongest possible terms, deny that premise. We
have been to programs that have taken people in the most severe
possible state and brought them to recovery. We are not
identifying throw-away people. And the way to most effectively
treat them earlier on as well as later is to have programs that
have to demonstrate accountability. Too much of the system now,
despite excellent people in the field, too much of the system
pays no matter what the results are; move bodies through. This
would give providers an incentive to move people from services
into transitional help, worry about how they reintegrate with
their families, with their jobs, with their housing and
stability. It would not just give no incentive to finish the
services, kick them out the door and submit the bill. I am not
saying good providers do that. They don't. But there's not
enough incentive, we think, in the system to identify those who
are better.
So we want an assessment at some period of time, and
perhaps 90 days after services are provided, that includes a
test to find out whether or not they are abstinent and rewards
on the basis who are effectively getting people into recovery.
If the client is not in recovery, we intend to try and
structure the system so they can go back and get services from
another provider that may help them get in recovery, because we
know that if there is relapse, the quicker we get people back
into services and treatment, the better off they are. We don't
want to let go of them and have them fall through the cracks on
the back end if there is a relapse either.
Now, that is more difficult than the current system
frequently provides, but if we are serious about the science
and the medicine and the result that we know programs can make
here, we ought to make that an expectation in the structure to
a greater degree. And we ought to reward people who have
results, and we want the reimbursement system to drive people
who provide ineffective care out of business. If you don't
produce results, you can't make up in volume what you failed to
do on individual cases.
Mr. Davis of Virginia. Let me ask Administrator Curie a
question. If you could capsulize why this is better than the
previous Federal treatment centers and why the $200 million per
year couldn't be better spent or just as well spent as part of
the block grant to the States.
Mr. Curie. Thank you, Chairman Davis.
Clearly what this initiative offers that we have not been
able to achieve or attain up to this point in time is: One, as
Director Walters outlined, a more efficient, quicker pathway to
accountability being a clear measure around these new dollars.
And you can do that with a new initiative as we shape it with
the standards in the RFA.
Second, consumer choice, which we referred to as the
epitome of accountability, clearly is essential here. It is not
an issue of certain providers having received block grant
dollars year after year and being primarily--while they have
been a mainstay--and again, we anticipate many of those
providers are going to be eligible providers to receive and
benefit from this voucher program as they are able to expand
capacity. But again, consumers will be in the driver seat, so
to speak, in terms of where they choose to obtain their
treatment.
I think the other aspect is that with these new dollars and
with the focus on taking a look at expansion of capacity, we
also can be very clear about the array of services that
encompass recovery and using recovery as a framework. And
again, as the voucher program succeeds, and as we move ahead
with implementation, we're going to be in a position to gauge
those results from the outset if we have the agreed-upon
outcomes.
Mr. Davis of Virginia. Thank you, Mr. Chairman.
Mr. Souder. Before yielding to Mr. Davis of Illinois, I
would like to welcome Mr. Bell of Texas to our opening hearing
this year.
Mr. Davis.
Mr. Davis of Illinois. Thank you very much, Mr. Chairman.
Following up on the voucher program, how do we ensure that
individuals won't just kind of shop around from place to place
looking for a miracle cure? Let's say I am at the Davis Center
for a month, and nothing seemed to have happened that has
changed my desire. And I say, well, I am not sure these Davis
people can do it, so I am going to run over to the Cummings
Center. How do we prevent that from happening with the voucher
program?
Mr. Walters. One of my colleagues is more expert, but my
experience in visiting centers is that's the course that can
happen right now. You can walk from one place to the other. You
can drop out. We have problems with retention as a part of the
programs.
One of the things this program would do is, of course, in
order to receive the reimbursement for the voucher, you have to
show that you are able to provide full services; you got to be
able to retain people as well as the results of that retention
and successful recovery. So in a certain manner here, we are
making the provider accountable by saying you have to keep
people in. We know for treating this disease, unlike, as an
example, an attack of appendicitis where you go to the doctor,
you have a pain, you want to get better, you comply. You know
that we have been involved in this in a long time, but there is
a lot of denial. People frequently come in and say, I don't
really want to stop using; I just want to get it back to where
I had more control of the fun I am having with drugs. And that
is a problem we all deal with in providing these services. But
we think the best way to do that is, one, make the provider
responsible for retaining contact with the individual so they
get effective services, and then measuring the effect of those
services afterwards, and if they are not effective at doing
that, then moving people to another provider who will be
effective. So we are trying to address the shopping properly by
the provider more than we are trying to change the behavior of
the individual client.
Mr. Curie. Along with the outcome monitoring that Director
Walters just described, also this system will be driven in
large part, too, by initial assessment, in terms of assessing
the need of an individual and a voucher being issued based upon
that assessment in terms of what the best course of treatment
and services would be for that individual. So it is not a
voucher that is going to have a face value to it to be able to
go from place to place at just clearly what the consumer
entirely would want to do, but it is going to be structured
around the assessment of that consumer's need as well. And we'd
be expecting accountability to be built into the system that
once a voucher is issued, that there would be oversight in
terms of a case management aspect of this as well.
Mr. Davis of Illinois. Dr. Barthwell, you mentioned
changing the culture of conversation as a way of convincing
more of this large pool of individuals who are in denial that
they are in need of services. Could you elaborate a little bit
more on that in terms of what some of the techniques and
approaches might be?
Dr. Barthwell. The demand reduction and implementation plan
of the strategy involved communicating very broadly with
Americans that the drug use problem is not just prevention or
treatment, particularly focused on chronic severe debilitating
forms of the disease and trying to drive more money in the
system to build a better ambulance at the bottom of the cliff.
It really also has to be about creating systems where we can
check the behavior of individuals who have moved past the
barricades that say don't start drug use and to get
nondependent users to recognize that they are on a course that
is going to change the trajectory of their life long before
that happens.
So we are trying to put speed bumps along the way, if you
will, to get the attention of the nondependent user, and we
also want individuals around the nondependent user who
typically looks the other way saying, well, they're doing
something, and it's not something I might do, but it really
isn't affecting me, to start to take some responsibility to
compel the user to get off of that pathway.
So our strategy is built around prevention programs,
strengthening our prevention programs and recognizing that all
of our efforts converge upon those two big goals, to reduce
drug use by 10 percent in 2 years and 25 percent in 5 years, to
get the nonuser to increase their resolve not to use, and to
deter the use. And we do that by having the messages that they
receive at home mirror those in community institutions and
having our laws and standards mirror those to really
communicate very clearly in a concrete way to young children
that drug use is wrong and drug use is not a good thing to be
involved in.
With individuals who have started using, whether they are
nondependent users or problematic troubled users, we want to
increase their desire to change by increasing their awareness
of their need to change. And we are looking at putting in place
more programs that detect use to deter, because we know the
detection programs do, in fact, deter use. We are also looking
at when those detection programs fail to deter, that the
earlier identification be linked with an intervention. So we
are working very closely with SAMHSA to have them drive
programs into hospital emergency departments where physicians
get better training in identifying someone who comes in after a
vehicular crash and intervening them and linking them with a
brief and early intervention.
There is a tremendous amount of science. We want to apply
this in a very broad way to drug use. And finally, for people
who have more chronic severe debilitating forms of the disease,
we want to increase their desire to change and help them to
stop using. And we think that the programs that we can do, this
being among them, to improve the ability of treatment programs
to reach an individual where they are so they can acknowledge
addiction, commit to recovery, and work them to reduce or
eliminate inducements to use are going to enable us to have
better success rates from our programs.
Naturally if you have a program that accepts all comers
with no screening, they get one out of four individuals to stop
at the end of the treatment program. We can do better than
that. We have programs that get 97 out of 100 who enter to
stop. We want to supply the science and technology that's being
employed in a two-tiered system to more a public system, and we
think this voucher system helps us achieve that.
Mr. Davis of Illinois. Thank you, Mr. Chairman.
Mr. Souder. One question I wanted to insert, I think, that
potentially would address a couple of the questions here, one
relating to the potential switching, from the Davis clinic to
the Cummings clinic, that the second part which would have to
do with the smaller residential centers with 12 beds, how do
they meet the standards you're developing? And even the third
one you just alluded to, which is prescreening and potentially
screening out, we had some informal discussions, and I wonder
whether this was going to be part of any of the standards of
controlling some of the payment to the groups. In other words,
if you don't complete the program, and you don't stay clean,
the firm itself doesn't get the money. If that is the
accountability, if there is a real action for not making sure
your people are cured, in effect, or at least through your
program are clean, then the financial burden and the standards
are going to be placed on the person who's doing the program,
or they're not going to get paid. And I am wondering if you are
actually involving that or whether you see that coming in the
standards.
Mr. Walters. That is our intent, and we will work with the
States to make sure that the way we build that in doesn't
create impossible work demands. I would expect--although it is
going to vary from State to State. There is some delayed
reimbursement. In some States there is now an audit after
reimbursement to see whether or not services were provided
effectively, and they may pull some money back or sometimes may
involve some additional money. So there is already in the
system some structures that are not unlike what we are
proposing.
What we are proposing is an assessment afterwards and
standards that fit the basis of the severity of the individual
case that individual providers face. We are not trying to drive
them simply to cream, as Dr. Barthwell indicated, although, as
she said, we want to help the people we can help more
effectively. On the one hand, we are not trying to make people
not treat a category of people. On the other hand, the creaming
is understood as something we really could help now. We want to
help them. And so--but the goal here is to use the addiction
severity indices that have been developed to compare like
candidates and to have real measures of effectiveness.
Not to get too far ahead of us, but my personal view and
not the administration, we have knowledge from the research we
have been funding, and the programs we have looked at involves
sometimes much more expensive, involved treatment. It's very
hard to fund that when the issue is how many slots you are
funding. You find cheaper treatment, and, therefore, the people
who may be helped by the more expensive treatment are not given
those services, and as a result their outcomes are frequently
not very good.
I believe that if we begin a process that assesses people
and shows severity up front, provide the different set of
providers, and we look at the outcome of those providers, and
we begin to say, let's not spend money on something that's
going to be cheap and ineffective, let's spend greater money,
but instead of just people saying, this must be better, you'll
have a system that shows the results to concretely justify the
more intense expenditure of resources because of the outcome.
We begin to have a system that can continuously show us what's
happening here, and so we can better manage and make judgments
about investment of resources for effective outcomes.
Mr. Souder. Mr. Clay.
Mr. Clay. Thank you, Mr. Chairman.
My concern has to do with the cost of the program. The
President proposed spending $600 million over 3 years to
significantly enhance the availability and accountability of
drug treatment in the United States. Does that mean diverting
funds from existing programs? And what will be the basis for
the voucher distribution among the States? Will it be based on
population, needs or what? Has that been devised yet?
Mr. Curie. These are all new dollars. They're not being
taken from any other pot of money. And these are all new
dollars to the Substance Abuse and Mental Health Services
Administration for that period of time. We are in the process
of developing standards by which, as we issue an RFA, we'll be
having States apply. Obviously, we want to have it based on
both documented need. Also we recognize there's difference
between States such as California and Rhode Island. So we're in
the process now of honing in in terms of what would make sense
for some sort of allocation, but, again, we want to base it
upon need.
Also the key here--we use statements that this is a
competitive process. I want to stress that when we say
competition, we're talking at a couple different levels. One,
States have to compete against the standards of the RFA. They
have to demonstrate that what they're developing is going to be
meeting the standards of the RFA. And, again, we want this
implemented in as many States as possible across the country.
At this point we're not precluding the possibility of trying to
do something in every State. Some States may choose not to
apply. But we also recognize that in dealing with $200 million,
once we have a response to the RFA, we will have a clearer idea
as to the breadth of the program across the country.
Mr. Clay. On a somewhat related matter, being from
Missouri, initially methamphetamine was manufactured and for
the most part used in the rural parts of the State. Now law
enforcement is turning up these laboratories in urban areas.
Have you all noticed a trend where the use is migrating from
rural parts of a State to urban parts of a State? And any of
you can try to tackle that one.
Mr. Walters. It's very general. The general trend of
methamphetamine has been that it started in the Southwest and
moved across the country. For example, we have had it for
several years in Los Angeles. We had it move to some other
cities in the West. Sometimes it has started in rural areas,
but there are also, usually depending on whether it's being
produced in small labs, which are frequently associated with
the rural use, but there are also large superlabs, as you
probably know--some are in the United States, sometimes there
are superlabs in Mexico--and then bringing large quantities in,
which can be more directly marketed into urban areas. It can't
be marketed in rural areas, but they can be moved in because
some of the organizations are also selling other kinds of
drugs, heroin, cocaine, marijuana. So they have already
established patterns of use.
But we have this moved essentially from the West to the
East, and in some cases it is first seen in a State in rural
areas, but sometimes it has also been showing up in an urban
area just depending on how it's produced and what the
introduction route is.
Mr. Souder. Mr. Bell.
Mr. Bell. Thank you, Mr. Chairman, and thank you all for
your testimony here today.
As the Chair kindly pointed out in his welcoming remarks, I
hail from the State of Texas where drug treatment is a critical
need, just as I'm sure it is in many other States.
Interestingly, just this past year, in December, the Texas
Commission on Alcohol and Drug Abuse did a study where they
found that the total impact of substance abuse in Texas cost
the State's economy more than $26 billion, and they broke that
down--came down to about $1,244 for every man, woman and child
in the State. So you can see it is having a devastating impact
on the State of Texas.
But my concern is this: With States suffering through
historic budget crises--in my State of Texas, the legislature
is looking on a $10 billion shortfall in this legislative
session--my concern is the cost of administering a program such
as this. Not only are States adjusting to the new data
requirements under the performance partnership grant, but those
who choose to participate in this voucher program, based on my
reading, will have to bear the brunt of the administrative
costs.
When considering pending State budget cuts, administering
these programs could adversely affect the very people we intend
to serve. Currently only small portions of existing grant
dollars can be used toward administrative costs, and under this
voucher program, my question is will there be caps placed on
the dollars going toward administrative costs? And if so, are
you concerned about the burden this may place on the States and
what can be done about that?
Mr. Walters. We certainly are concerned about the problem
of how much of the resources we want for services get pulled
off in nonservice delivery here. And I met, in fact, with Dave
Wanser from Texas, single State agency, just a month ago and
talked about the pioneering program Texas has and linking
electronically individual providers to a reimbursement system
that will save enormous amounts of money. I think SAMHSA is
already interested in doing this so that the paperwork is not a
matter of multiple copies of different forms, but a Web-based
system where information about clients, the assessment and case
management information, is wed to reimbursement information,
and that pulls from that the information we need, from reports.
We're not sending multiple forms and requirements. We're
reducing the staff costs. We want to cap the administrative
costs of this program.
We also want to reduce administrative costs, although we
are seeing some variation here. Different States have different
capacities.
We also want to reduce the cost of providing services that
are not utilized. One of the things I mentioned earlier that is
attractive, especially in this budget climate, is that we would
pay for the services provided. We are not paying for a facility
or a place where there's a bunch of slots, and the maximum we
could hope for was use 100 percent, but usually we're going to
use less than that. When we pay for vouchers, we're paying for
an actual delivery of service to an actual individual.
Yes, there probably would be some additional expense
associated with the followup assessment. Right now I suppose
there may be some additional assessment or cost in providing
the reimbursement perhaps, or to bring new providers in line.
But I don't think, given what we know about the system now,
that is likely to be significant, and I think it's just not pie
in the sky promises that the savings on efficiency, the savings
on funding programs that work, the savings on giving programs
incentives to change as a result of the reimbursement mechanism
should vastly outweigh the costs that are involved here, but we
would not allow uncapped administrative expenses as a part of
this program.
But I would let Mr. Curie talk about the structure that we
have decided on so far.
Mr. Curie. We're anticipating that in the standards, that
we would be giving guidance in regards to use of any of the
dollars to cover administrative costs to the State, and, again,
we would anticipate that being capped. At the same time these--
one major advantage is that we're not requiring any State match
or efforts made of these dollars. So that also gives the States
some greater latitude with these dollars.
Dr. Barthwell. I would also like to add that we do expect
that there is a clinical assessment that is done before a
person is matched, and that the post-treatment assessment would
be clinically allowable costs and not a part of the
administrative overhead. We also spoke with Don Weitzman, who
is the associate director of Dakarti yesterday, and you have a
5 percent administrative overhead allowable in Texas, and last
year you didn't use all of it. So they are actually operating
at--a little slimmer in the way of administrative costs than
some States are.
Mr. Bell. Thank you.
Mr. Souder. I would like to yield to Mr. Cummings.
Mr. Cummings. Thank you very much, Mr. Chairman.
As I listen to the questions of my colleagues, I just
wanted to ask you about a few other things. Director Walters,
if I've got a Cadillac program, and then I've got a Pinto
program, and I've got a voucher, Cadillac program costs me
$100, the Pinto $20, how do I control--I know the States have
regulations, but how do you foresee having some kind of balance
here? I know at the end you will look at the results and see,
and you will maybe look at some costs from the beginning, but
the other person goes in there and every week he's going in
there, $100, $100, $100, and then--but he could have gone to
the $20 program that may have been just as an effective.
Because, as we all know, sadly, and all we have to do is look
at Medicaid fraud, a lot of times when people find a way to
reap dollars, they do it. We have a few bad apples; 99 percent
of the people are great, but the few--and with the limited
amount of money that we're dealing with, I am just trying to
make sure that we have the safeguards that we need.
And so all of you have talked about how we, the Federal
Government, what we say to the States. And so how do you deal
with that kind of situation, because I can see that happening
because I have seen it just trying to help people get
treatment. One program is sky high, and another one is real
low. What do you foresee there?
Mr. Walters. I will let my colleagues who have more
experience respond in more detail. I think this program for the
first time lets us address that problem. We will assess people
at the point where we give them a referral and give them the
voucher. If they need more expensive residential treatment
rather than outpatient treatment, that would be a determination
made at the point of assessment. Then the referral would be for
that category of treatment with providers, I presume, in the
States--although we haven't settled all this yet--that would
agree to provide those services within a certain range of
costs. If we find then that some of those providers can provide
effective services at a much lower cost, then we obviously
would have the information that's necessary to say, why don't
we learn from what they're doing and provide more people
effective treatment at the lower costs.
There may be some variation. There always is in
circumstances and situations. One size doesn't fit all. You
can't always compare people that are in more expensive
environments. And I suppose there is some variation. For the
first time--it is not that the voucher is good for anything you
want, it would be determined on the basis of the assessment,
what range of intensity and expanse of services. And then
within those particular providers, we would have over time an
indication of what was the more cost-effective route, whether
it is more costly or less costly.
Obviously, we would like to be as efficient as anybody, but
we would begin to have the data that shows who is making the
difference.
Mr. Cummings. You went right where I wanted you to go, the
data. Do you foresee a day, once we get the data, that we might
say, the Cadillac program, we love you, you're nice and all
that, but we just can't--do we--do you see a date when we say
that either you are going to bring your costs down, or we are
going to have to say this is one program you cannot use with
the voucher? Do you foresee that kind of thing?
Mr. Walters. Sure. I would imagine with responsible
stewardship that we would build into this partnership with
States saying, if you don't do with a lot more money what you
can do with less money, because there's always going to be
limits here--but if the system works, we would begin to have a
record of each provider so we not only can refer you to
somebody, we can tell you what their effectiveness is. There
really is consumer choice based on knowledge, and that's when
it has meaning, and that's when you begin to say we are
providing a system that maximizes the skills we have as a
Nation to make people well and to help them get into recovery
and stay there. It's not a shot in the dark.
Mr. Cummings. Just on that note, when you said that, it
reminded me of health insurance open enrollment thing where you
sort of pick and choose. Do you foresee a time when maybe you
may say--have some kind of document that says just based on
pure data that this is what we have seen, these are the
results? I don't know how deep you want to get into that. Do
you follow me?
But again, following the yellow brick road, trying to get
to the most effective and efficient use of dollars, it seems to
me like you would almost have to, at some point in this
evolution of making the program the best that it can be, get to
there where you are actually listening to stuff and what's
reasonable and what's not.
Mr. Curie. I think you have actually addressed the ultimate
place we want to be, and that is if you want to call it
scorecards or report cards at all levels. In other words, we
are going to require States to have a credentialing process,
which I would view as a dynamic process, as we establish
standards, and in that credentialing process also permissible
rate ranges based on modality being part of that as well; and
then as time goes on, as you indicated, in terms of a list of
outcomes, that there can be a day which we would hope for that
when consumers are making choices, and they have a choice of
certain providers within a particular modality based on the
assessment, they can make an informed choice based upon a
scorecard of outcomes, consumer satisfaction and make an
informed choice. And I think that that is part of the evolution
that we see in this process.
Mr. Cummings. Just one other thing I want to say on the
record, Director Walters, and I forgot to say this from the
very beginning. I want to say it publicly. Deputy Director
Salzburg has been absolutely incredible. She has been to my
district twice in the last 3 or 4 months trying to help us
address some very pressing needs, and I just wanted to make
sure I said that on the record.
Mr. Souder. I want to make sure, in the responses to Mr.
Cummings' questions, that one of the big innovations in this
program is this idea of going down to the small residential
centers of 12 people to look at Hispanic, African American and
other minority centers that have traditionally been excluded.
We don't want to make something so bureaucratic and so
scorecard-oriented that small providers can't get into this,
because part of what's been happening is rather than
necessarily a Pinto, let's say VW Bugs of the world actually
may be producing as good a result or better than some of the
big ones, particularly in the hard-to-reach population, but
they haven't been involved in these kind of programs.
As a firm believer in capitalist principles, which I
believe you're building into this program, in effect if someone
doesn't provide an effective program, they're going to go broke
because they won't get paid. If you withhold some of the
payment, they won't be there for very long. Most of these
places are struggling already, and what we don't want to do is
make it so that only the people that know how to work the
insurance system or the people who know how to fill out the
forms or the people that know how to market with their
advertising programs are eligible to do drug treatment, because
so much of this is happening by the love and the individual
commitment, and that's partly the innovation of your program.
So don't overbureaucratize the program in developing it.
Mr. Davis had an additional question, too.
Mr. Davis of Illinois. Generally and oftentimes when we
talk about reentry, people begin at the point of an
individual's termination of sentence, and they're now ready to
come back into the community. And while I recognize that while
incarceration is in effect, these individuals under the
jurisdiction of the various justice and correction facilities
and institutions of which they are a part--but I really think
you folks know more about treatment than they do--are there any
serious efforts under way to convince justice and corrections
people that they should look seriously to increased treatment
while individuals are under their jurisdiction, are
incarcerated?
Mr. Walters. Yes. In my written statement, in our own
budget we are proposing an expansion of Federal support for
drug courts. We have tried to allow more Federal resources of
treatment to go into the criminal justice system in various
levels. We would like to do more of this. We would like to have
this program also have the flexibility based on States'
determination of need of helping people who come into the
criminal justice system if they need a voucher for treatment.
I know there is a view that in some places people come in
once, and they get harsh sentences. The problem we face in most
jurisdictions that I have visited is the people come in over
and over again, and it's not until something serious enough
happens that they finally get into the criminal justice system
or they get into something like drug court. It's the reverse.
We're not reaching out to people when we first should
assess them because of lack of capacity or resources or lack of
confidence that it really is going to be cost-effective. We did
not just say that we believe treatment would save lives and
save money. We're trying to build a system that acts on that
principle in a more aggressive way, so when someone comes in or
when someone is in another community setting where they show
signs of needing services, there's more people to assess them,
and there's a more direct link between if you discover it, you
can actually help them.
Of the roughly 6 million people we talked about needing
treatment, 23 percent are kids. They're in schools. They're in
pediatricians' offices and general practitioners' offices.
They're coming into community centers. They're coming into the
criminal justice system as their problems get worse. Before
they become a serious felon, or before they drop out of school,
or before they fall away from home or don't see pediatricians
anymore, we want to encourage people that reach out to them by
giving them a clear statement of obligation--that's the
cultural change that Dr. Barthwell spoke about--but also we
want to provide a direct tool to use to get these people help
even if it's less intensive help earlier on, because we know
that creates the greater chance of recovery.
Mr. Davis of Illinois. I am saying specifically, though,
while they're in the penitentiary, while they're in jail, are
we talking to wardens and prison officials saying that you
folks might want to look at increasing the amount of treatment
that you provide to these individuals while they're inmates?
Mr. Walters. Sure. We also agree that we think to optimize
this we need to pair the incarcerated treatment that we're
providing to reintegration programs out in the community. I
think there's no question we increase the effectiveness of
those programs when we do that, and dramatically. So we want to
do that as well.
But I don't want to be understood to be in any way evasive.
We want more treatment in the places where people have problems
are, and one of those places is prison.
Mr. Souder. Before yielding for Mr. Mica, I have some
additional written questions I will submit.
I also want to reiterate a couple of points that you have
made here, and I think they've significant, and we look very
much forward to seeing how it comes down to the details. And
when you put your RFPs out, the idea of having the different
dollar size based on the assessment because some people are
going to take more treatment is a very valuable tool. I think
your tough accountability standards is a new innovation that we
need to have, and actually having accountability with that, not
just that they did the test, but that would be tied to whether
or not the company gets its full funding. I think this should
also lead to those programs that are effective being even
stronger programs and more known for their effectiveness.
But your flexibility in the vouchers and reaching out to
new groups with flexibility of addressing it is another
important innovation, and you have expanded in a little more
detail today that has been very helpful, and we will be very
much looking at the specifics.
Clear, we didn't get into the faith-based fireworks today.
We know we're going to be dealing with that. We look forward to
working with you. We know part of the difficulty this is--many
of these very effective programs are predominantly religious,
and clearly dollars can't be used from the Federal Government
for the religious portion of it, and this is going to be our
most hotly debated part on the Hill. And as we move through our
hearings on faith-based in general and on this program, we'll
look at those nuances. I have differences with some of my
colleagues in how far we can go on that, but there are
Constitutional limitations, and this is going to be probably
the toughest part of your RFPs when you put it out, and I look
forward to working with you as you develop that.
Mr. Mica.
Mr. Mica. Thank you, Mr. Chairman. And one of my concerns
is that we've made some of the treatment programs sort of
swinging doors, and we have people coming in and out of these
programs for a short period of time and not very successful
results. It appears from what we've seen there are a couple of
successful programs. The faith-based have a very high rate of
success that I've seen, and then longer-term treatment programs
that are sort of holistic in their approach, they address a
whole range of problems, but not the short 30-day, sometimes
60-day.
Is there any way we can be assured that this new program,
voucher program, is directed toward these more successful
programs? Is there any way to start taking money out of these--
they are sort of treatment mills that have sprung up that
aren't that successful. I mean, we need to put the money where
they can do the most good. Can you respond?
Mr. Walters. Yes. One of the fundamental principles that we
try to build into this is that the reimbursement system based
on an assessment of the effectiveness of the services provided
would be a vehicle for determining effectiveness and changing
the dynamic of the marketplace so that programs are not
affected--that are not effective do not continue to be funded.
So the direct way to stop the revolving door, whether that is a
result of taking in people, letting them drop out at high rates
or taking in people, giving them adequate care, is that there
will now be on a case-by-case basis under this program an
evaluation of what happened to the person, and the payment to
the provider will be based on being successful. It will vary
depending on the severity of the individual.
Mr. Mica. Will there be some way to stop--I mean, you're
going to be getting data that will be received sometime much
later in the treatment process, much later. Will you have an
automatic cutoff if this isn't successful, and what data are
you going to encourage the States to use in establishing
whether their programs receive funds under this new program?
Mr. Walters. We'll work with them on some of the specifics,
but the general principles that we've talked about in closing
in the program is that some point after services are completed,
like, for example, as I said earlier, 90 days, there's a
subsequent assessment of the individual. That assessment, we
are saying, must include whether or not they are abstinent. It
can include other factors, have they been involved with the
criminal justice system, are they employed and stable, but it
must include are they continuing to use substances----
Mr. Mica. Maybe I should back up, because this is 90 days
into it. Most programs I have seen that are successful are
longer term. When we get in trouble is when we have these 30-,
60-, 90-day wonder programs, and they're out for a little
while, and they're back in for another 30- or 60-day shot at a
program. And sometimes this is--I mean, I can give you many
cases of just people I personally know that have had family
members with an addiction problem, and we have the mills that
are treating them, and we don't have the results.
That's why I go back to the original part. Is there any way
to make certain that this is directed toward programs that
already have records of success like faith-based, where we
have--you know, some of mine have a 90 percent success rate. Or
DETAP, for example. You're familiar with DETAP?
Mr. Walters. Uh-huh.
Mr. Mica. I mean, we visited there. I think Chairman Souder
and I were up there, maybe Mr. Cummings joined us, but they
took some people that had been addicted for years and had
criminal records and in and out of the system and treatment
programs all over the place, and they turned some of those
folks around. I thought it was a miracle program, quite
frankly, and that is the kind of program I'd rather spend the
money on. And I'm not sure that this new program is so
directed, especially when you tell me that after 90 days----
Mr. Walters. I don't think I was clear. I meant 90 days
after the program says it's completed the services to the
individual. If those services take 180 days----
Mr. Mica. Can you back up and go to, again, how do we
ensure that the money gets to these successful programs? Do you
have some criteria right off the bat to----
Mr. Walters. We would work with the States to determine who
is eligible to be a provider under this program. They would
indicate who they would allow as a referral, and since it is a
competitive process, we can look at the strength of the
criteria they use to select and for effectiveness as a part of
the choice of whether or not they are a participant. In
addition----
Mr. Mica. Do you have any kind of rating system in place or
certification of these programs?
Mr. Walters. Well, there is a certification system now in
place.
Mr. Mica. No. I mean, based on success.
Mr. Walters. It varies. I'll let Mr. Curie talk about----
Mr. Mica. Because maybe that is something we should look
at. Again, I see dozens and dozens of treatment centers across
the landscape and, again, the revolving door that concerns me,
and I have no problem. I'll put all the money that we could
possibly put into programs that are successful, but it's just
the frustration of, again, putting people in these short-term
mill programs that have sprung up and that aren't successful.
Ms. Barthwell. Might I add a little bit to that. There is
very clear criteria that's been established by the American
Society of Medicine. There are others. It's been employed in
the State of Illinois. It's been employed in Massachusetts. So
there's experience in both the research domain and the clinical
domain that shows that there's a good relationship between the
severity of the disease and the intensity and the length of
treatment in terms of predicting an outcome.
The American Society of Addiction Medicine's domains that
they measure are acute intoxication or withdrawal; the
biomedical problems; the emotional behavior, complications
associated with it; but more importantly as it relates to why
someone would need one of the long-term therapeutic community;
relates to assessing their treatment acceptance or resistance,
whether they have an insight into the nature of their disease
and whether there's a potential that they're going to be
compliant, whether they're highly symptomatic and have skills
to keep them sober, and whether they need structure and
support.
But not everyone who uses drugs who comes in for treatment
needs a DETAP village in order to be successful, and what we
want to drive into this program is an assessment as they enter
treatment to determine who would need that so that they don't
get the 30-day program.
Mr. Mica. I just don't like two tries and you're out of
these quick-shot treatments.
Ms. Barthwell. We certainly hope they don't get matched to
them if they need something more.
Mr. Mica. You just hear so many people that have had their
kids in or their family members in time after time, again, and
they are programs that I don't think are successful. And most
of the programs are geared to this shorter-term treatment. So
I'm trying to figure out how you--how we give some preference
to the longer-term treatment.
I mean, OK, you've got an individual who is addicted, and
they have one shot at maybe one of your one-stop, quick-wonder
treatment programs, but then two and three bites at the apple.
When do we sober up and say we need--this person needs some--if
we're going to put Federal money into this, we need a program
that is going to be successful and has some basis for success.
Mr. Walters. I hope--I'm not sure that we're doing what we
should do here. We need to convey to you that concern is at the
center of what we're doing, that the current structure--I think
sometimes even in the private market, but certainly in the
government market, has drifted not in all cases and not all
places we want to have a slot for everybody, and we're not so
much concerned about the results of that experience in enough
cases as we are the fact that we can say there's something
there. The worse thing we can have is not something--we still
don't have something for a lot of people as we talked about,
but our goal by this case-by-case monitoring and evaluation and
reimbursement on the basis of effectiveness is to drive the
system to produce better results for each individual, even if
they're more intensive and involved, so that we have the
ability to both see cost efficiencies, but also to see cost
efficiencies that may involve much greater investment up front
that actually works.
Mr. Mica. Well, just--and I know my time is expired, but,
again, I think we ought to look at something, because, folks,
we're paying for this. Everybody says long term is the
expensive. Well, you go back and look at these cases you're
doing of 30 and 60, the short term, but you do 4 or 5 of them,
and then the interlude disruption, the social disruption,
they're out committing crime, they don't have a job, they're
back in the system, and we're doing long-term, in effect,
because most of them have three and four shots, and they're
still addicted. And you add that up, and I'll bet it's less
than the cost of a longer-term successful program. So at some
point I think we've got to find some way to make this
successful and what works being funded, at least from our
Federal investment standpoint.
Thank you. I yield back the balance of my time, Mr.
Chairman.
Mr. Souder. Thank you. We'll use it very wisely.
I appreciate you all being here today and fielding the many
questions and taking the time with us. I'm sure there will be
many followups, and this is just the start of your adventures
on the Hill, but we appreciate starting with your committee and
thank you for your work, all three of you.
With that, if Dr. Boyer-Patrick would come forward and
remain standing.
If you'll raise your right hand. As you heard, as an
oversight committee, we take our witnesses under oath.
[Witness sworn.]
Mr. Souder. Let the record show the witness responded in
the affirmative.
Thank you for your patience. You get the opportunity to be
the first one on Capitol Hill to respond to the Federal
Government's initial proposal in the treatment programs.
Welcome.
STATEMENT OF JUDE BOYER-PATRICK, M.D., M.P.H., HAGERSTOWN, MD
Dr. Boyer-Patrick. Thank you, Mr. Chairman, and good
afternoon, and to the members of the subcommittee----
Mr. Souder. Could you hold just a minute? The mic isn't on.
Try it again.
Dr. Boyer-Patrick. We'll start again.
Good afternoon, Mr. Chairman, and members of the
subcommittee, with a special hello to Ranking Member Elijah
Cummings from my home State of Maryland. Thank you for inviting
me to testify about the administration's new drug treatment
voucher initiative.
As an addiction specialist and a child adolescent
psychiatrist at Brooklane Health Services, which is a 50-year-
old private nonprofit behavioral health program founded by the
Mennonites in Hagerstown, MD, and the former medical director
of an addiction program in Annapolis, MD, and a member of the
Maryland Governor'S Drug and Alcohol Council, I have spent
significant time thinking about how to expand and improve the
drug and alcohol treatment system and maximize treatment
options for my patients.
Investing new funding in the treatment system is critical,
because the treatment gap looms large, both in my State and
nationwide. In Maryland there are approximately 250,000
individuals who need drug and alcohol treatment, while
nationwide that number is much larger.
The administration through President Bush and drug czar
John Walters have shown great leadership by proposing an
additional $600 million in the drug and alcohol treatment
system at a time when there are many competing priorities of
national importance.
However, while the drug treatment voucher program proposes
significant additional funding, the program will require
safeguards to ensure that it provides the most effective
treatment in an efficient manner. These safeguards include
ensuring that the voucher program supports evidence-based
practice. The science of addiction medicine has greatly
advanced during the last several years through genetic studies,
brain imaging and medication development. It is important that
the focus on evidence-based treatment continue, and that drug
and alcohol treatment expansion helps to support access to this
cutting-edge care, holding faith-based programs accountable to
the same standards of care, performance and licensure
certification as all other licensed or certified programs so
that patients receive appropriate quality care for this medical
condition. States must have the power to require uniform
licensing or certification of all addiction treatment programs,
including those provided by faith-based groups, to avert
malpractice and maximize the life-saving power of these
services, protecting States, local governments and drug and
alcohol treatment providers against unfunded costs of the
voucher program.
Because the voucher program is a new program that will have
separate administrative systems attached to it at the State,
local government and treatment provider level, it is important
that States, local governments and providers are able to use
voucher grant or other Federal funding to pay for these costs.
For example, it will be difficult for States, local governments
and providers to pay for the tracking costs associated with the
performance outcome component of the voucher proposal without
voucher funding or other Federal technical assistance funding.
Ensuring that providers receive payment for the treatment they
provide, as referenced above, the voucher program proposes to
track the outcomes of treatment to evaluate treatment programs.
While evaluation and performance studies have long been
part of the treatment system, and many providers, especially
the ones in Maryland, are comfortable with this fact, I am
greatly concerned about the voucher program's proposal to base
payment for each patient's treatment on resulting outcomes.
First, the time it takes to gather outcome data would create a
significant delay in the time it would take to pay providers,
and this day would harm most programs financially. Second, no
other medical treatment bases payment for past services on
outcomes. For example, physicians treating hypertension or
diabetic patients also receive payment regardless of whether
those patients take their medications, eat a proper diet,
exercise, or modify their other health behavioral problems.
Performance-based payment for previously provided treatment
is inappropriate. Using performance measures to evaluate past
performance as a way to manage future investments in the drug
and alcohol treatment systems and its providers would be a
better goal. Provide patients with real choices. The voucher
program should require faith-based providers to clearly state
that patients have the right to choose another provider,
including secular medical model treatment providers before
treatment should begin.
Prohibition of diversion of substance abuse prevention and
treatment block grant funds to the voucher programs and to
ensure that the new funding expands drug and alcohol treatment
in as many States as possible.
Finally, I urge Congress to require that the
administration, while developing the program, and States, while
implementing the program, set up advisory councils to guide
them through these efforts.
In Maryland I have participated in the Maryland Drug and
Alcohol Council and the Maryland Drug Treatment Task Force,
where both have reshaped and guided Maryland's drug and alcohol
treatment system by gathering expert advice as well as public
input. Our system of care in Maryland has greatly improved as a
result of this process.
Expanding alcohol and drug treatment and prevention is
critical. So many lives depend on these services. I hope that
Congress and the administration will consider seriously the
recommendations I have discussed today.
Thank you for hearing my testimony, and I would request
that my written remarks be added to the data. Thank you so
much, and I'll be happy to answer any questions.
[The prepared statement of Dr. Boyer-Patrick follows:]
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Mr. Souder. I thank you for your testimony, and you've
raised a number of difficult questions we're going to sort
through, but let me start with your example on the terminally
ill cancer patients is absurd.
Dr. Boyer-Patrick. No. I didn't say terminally ill cancer.
I said hypertension and diabetic-type patients.
Mr. Souder. It says providers treating terminally ill
cancer patients receive payment despite the fact that their
patients will die. And the fact is, is that the fundamental
question here is what is the point of drug treatment? In other
words, if it is a curable--something that is curable, some of
us would like to see that in other parts of health care as
well, because we're very frustrated at the accountability in
the bureaucracy. That's not to say individual programs haven't
been effective, and we've all met people through them, but the
fundamental fact that the industry has to look at is every
single one of us on the street have met people who have been
through seven, eight, nine programs, that the programs have
reported--those same programs where I've talked to individuals
have reported to us that based on science, that person is
cured, and then they relapse.
Some of the nonscience-based programs where I've met people
who have been off cocaine for 20 years after Johns Hopkins
Hospital in particular told me they could not do it, and they
went off overnight, and they're still clean 20 years later.
There is a problem, in my opinion, you need a balance between
our science fact-based things and things that have been erected
around the process that protects the existing providers who
don't want to be held accountable. And I think that you've
raised some fundamental questions. We can't turn that into a
big scam. We don't want to undermine the existing structure,
many of which already works, and at the same time we have to
have some kind of what I would say helpful input from the
existing provider community rather than an overreaction in
saying, look, we don't want to be subjected to accountability.
You're going to be subjected to accountability. The
question is what is a fair way to do it? Some of it is process,
and some of it is results, because like you pointed out, some
people don't follow what you tell them to do. How can you lose
all your funding if they don't follow what--on the other hand,
there's got to be some measurement in a curable disease as
opposed to an incurable disease, and it should be in other
parts of health care as well. And I'd appreciate your response.
Dr. Boyer-Patrick. I think that's a very complicated--thank
you for sharing your thoughts, Mr. Chairman, and I guess
working in the field for over 20 years, this is what I've
noticed. And if I may use Mr. Cummings' reference to Cadillac
versus Pinto. I think the big part of it is reaching a person
when they're ready. As a provider, what I have noted--and I
have to reference back to what you were talking about. This
program is for people who do not have insurance, because those
people with insurance usually get treatment, and that is not
necessarily the case as we found in the State of Maryland.
There are barriers to entry.
My concern is when a person is ready for treatment. There
are many reasons why people seek treatment. A lot of times
people seek treatment because they're going to get kicked out
of school, kicked out of home, their parents are tired of them,
the boss is going to fire them, the wife is going to kick them
out of the house. So there is a window of opportunity sometimes
where a person wants to get that treatment and the treatment is
not available because of lack of money for a majority of the
people in the city of Baltimore or a lack of bed space. And the
treatment facility that I worked at for 5 years, we had beds,
and people had insurance, but they were not allowed to come in
because of barriers to entry. And so we tried to make that more
uniform.
So there is no way to know, Mr. Chairman, when a person
walks in the door, be it the Cadillac or the Pinto, whether
this is the one that is going to make it, but we don't change
our strategy because this one looks like this one is the one
that is going to make it because when they walk out of the
door, they have a good family background, a network in place,
they've been sent to a group home, they've been sent to a long-
term residential.
There are a number of reasons that have to come into the
pie as to why a person will make it and a person won't. We
don't have a crystal ball to determine that, but I will let you
know that there are many wonderful treatment programs out there
that have licensed excellent staffs and do good work, and yet
it's still 50/50. It's like guessing which is going to be--if
it's going to be a boy or a girl without using an ultrasound.
We don't know when the person walks in the door, and I just
feel that to judge a program based on whether the 10 people
come in and 2 make it versus 9 does not mean that that
therapist is not a good therapist.
I guess that's sort of where I'm going with this.
Mr. Souder. But that's the way the world works. I had a
retail furniture store, and each person could give me an excuse
why they didn't sell as much that week, but ultimately part of
the accountability is results. And, yes, the customers walk in
with different qualifications. Some have more money. Some of
them are more interested that day in buying. There's an
accountability process, and with a number of programs that I've
visited, quite frankly, they have a 90 percent success rate,
and they have harder cases, in urban San Antonio, in urban
Chicago and other places like that, than many of the programs
who say that they only get 50 percent success rate. And that is
partly what we're trying to address here is some of these
programs that are grassroots-based, who live in the
neighborhoods, who daily respond and who hardly get payment,
and some of them--I've met some programs in Boston and in other
places where they don't even have health insurance for their
staff, but because they're invested in their community, they
don't meet all of the great criteria, but they're getting
people cured. And that's part of what we're trying to figure
out how to address.
I don't mean to denigrate the advances of science or the
passion and the commitment of the people in the existing
system, but there's a mismatch here.
Dr. Boyer-Patrick. Well, I would agree with you, Mr.
Chairman, and if we could find out a way to make that match
work, but at the same time you want outcomes, and you have to
track outcomes, and you want everyone to be on the same playing
field. I'm not saying that a program that is in the inner city
or that is faith-based would be better suited to do the work
that you want to do at a lower cost than the Cadillac program,
who probably has a good program as well, but has lesser
outcomes for whatever the variable is. My issue is that if
you're going to require tracking outcomes, it should be on the
same playing field. You can't hold someone to a higher or
lesser level or standard.
And so I'm not saying that the voucher program isn't a good
program. I think it's a good way to meet the need for many
people who do not have access to funds, but once they have that
voucher, who is going to make that decision? Where are they
going to go? To the Pinto, because it's better and cheaper? To
the Cadillac, because there's a bed available? To long term
because since my work is with children and adolescents, I know
that with adolescents, because of their developmental level,
they have no abstract thought, and they think that it's now or
never, and it's not going to happen to me? Treatment for
adolescents takes way longer than treatment for an adult who
may have more hammers over their head, and they need to do it
more. So we have less adolescent treatment. We don't have the
time.
Now, the reason why people are in and out and in and out,
because that's managed care. I can guarantee you that there are
many times we'd like to keep them longer, but we cannot keep
our doors open if we can't get paid, and the system that is in
place right now will not allow us to do it. So we do the best
we can with the time we have. It's not a perfect system. But I
think there are a lot of other parameters that have to be
looked at before this is all said and done.
Mr. Souder. And I think you've raised a very important
question. There can be a double standard in accountability, and
we have to work that through to be fair to all. Thank you.
Mr. Cummings.
Mr. Cummings. The discussion that you all just had is an
issue that has been raised in this committee before and is an
extremely complicated issue. One thing that you will find that
I think we all share, Democrats and Republicans, is that we
want our tax dollars to be spent effectively and efficiently,
and I'm sure you share that.
As I'm sitting here listening to your discussion with the
chairman, I was thinking about how shaky drug addicts can be.
I've often said that when I talk to--I've had relatives who
were drug addicts, when I talk to them, I always would say to
myself, I'm talking to a ghost of the person I knew. It's not
the person I knew, because the person I knew wouldn't lie to
me. The person I knew wouldn't cheat on me. The person I knew
wouldn't take my lawn mower, say he's borrowing it, and then
sell it to the nearest pawnshop.
And I would guess that when we're trying to measure
treatment--and I guess this is a point you were trying to
make--I guess there are a lot of reasons why people may not be
successful. If a person is that shaky, then--and somebody said
it--I think it was Dr. Barthwell who said it a little earlier.
If a person is that shaky, almost anything can throw them out
of treatment. In other words, they could have been faking it
from the very beginning. They could have been. If a mother
says, I'm going to throw you out of the house if you don't get
treatment, the kid goes in, gets treatment, something different
happens in the household, the child feels that they can get out
of the situation, then they may drop out of treatment. I don't
know.
But I guess what I'm trying to get to is how do we make
sure--going to what the chairman said, how do we make sure as
best we can that we're not being treated--that people are not
gaming the system, I've been a very strong proponent of making
sure the treatment--that we don't have shams, but on the other
hand, we have all of this shakiness with regard to the patient,
with regard to the circumstances that a doctor cannot control
or a provider cannot control, where's the middle ground there?
I read your statement. In the same paragraph it says,
using--the last sentence, it says, using performance measures
to evaluate past performance as a way to manage future
investments in the drug and alcohol treatment system and its
providers would be a better goal, but, I mean, what does that
mean?
Dr. Boyer-Patrick. Well, I'm trying to think of the best
way to put it. I guess as a provider it's been difficult for me
to address how do you know when it's for real. And it has been
of great concern to me that the drug and alcohol problem is the
only problem medically, and I think it's a medical problem,
that is more held to you have one or two chances to get this
right, or it's done. That's it. Two strikes, you're out; three
strikes you're out. I've met people at Betty Ford who said it
took nine times. When I said hypertension or diabetes, I look
at substance abuse as a chronic illness, and sometimes you have
your periods of crisis, and then you have a flare-up.
I also look at it as tools. You come to me for
hypertension, I give you the medication. I have no control over
whether you're going to do what you need to do. We have an
obesity problem in our children and adolescents in this
country, and we talk to parents, don't do this, don't do that.
They do it anyway, because we're dealing with human beings.
But there seems to be so much more at stake, because
there's a limited amount of money available, so what we say to
a drug addict is, you've got this amount of time to get it
right, and if you don't, then it's over.
Are you going to have people who beat the system? You bet
you. That's where all the research has been going into over the
years over recontemplation and contemplation and readiness for
treatment. If we can get the person at the right time in the
right program, then we can probably have 100 percent success,
but we're dealing with human beings here with a very, very
difficult disease to treat, and the only reason why we keep at
it is because we win sometimes.
But there's no guarantee that we're going to win all the
time, and I guess my concern is not that we try to help or give
the opportunity to people who have never had it or to make beds
available or payment available for someone on the first go-
round, but when do we end? It seems to be not until they decide
it's over or they drop dead or--I mean, we've lost kids. I've
lost kids who have overdosed on heroin a week or two after they
have left my treatment center, in a bathtub at a friend's
house, but I also have kids who are still clean and sober
today, and the ones we thought would make it don't; and the
ones we say don't have a chance do. There's no magic ball to
it.
But I understand that there's a finite amount of money, and
that's the dilemma, and all I'm saying is that there are good,
well-meaning treatment providers who give good services, but
when I talk about substance abuse, Mr. Chairman, what I say is
if you're ready, it doesn't matter what treatment service you
go to, and if you're not ready, it doesn't matter what
treatment service you go to. That's it in a nutshell.
Mr. Cummings. We're going to talk about faith-based at
another time, and this is not necessarily a faith-based
question, but I think about--when I think about faith-based,
you said something about trying--when setting the standards,
making sure that there's certain components of the treatment, I
guess, and a lot of--let me just finish this.
My church has a drug treatment component, and we have some
volunteers who do this in life. This is what they do. My church
has 10,000 members, so we have some folks who can volunteer,
come in and help out, but I think the main component of it is
this self-help discussion. I don't know what you call that part
of it, discussion piece. And then they also have the higher
power element there.
Dr. Boyer-Patrick. Twelve steps.
Mr. Cummings. Right. And I take it that there is a clinical
type of the treatment piece, and then there are other pieces
that come to play with regard to that supportive--supporting
each other, discussing the problem, situation.
Dr. Boyer-Patrick. Mr. Cummings, there would be no way that
a person in a community could even make it without those type
of organizations.
Mr. Cummings. Oh, I agree.
Dr. Boyer-Patrick. Because, as a matter of fact, we highly
recommend that if you go through a clinically based medical
model-type treatment, that the people who have the greatest
success are the ones who link up with those faith-based
organizations. The very first Al-Anon meeting I attended 20
years ago was in a Presbyterian church in California.
Mr. Cummings. And the issue for us is not faith-based. A
lot of us believe in faith-based. We're just trying to make
sure--our issue is more of whether the faith-based organization
will discriminate, not that the faith-based program is not
important and plays a significant role.
But this is what I want to get to. Do you see as you've
read the material that you've read in regard to this effort,
this recovery effort here that the drug czar was speaking
about--what do you see the role of faith-based organizations
being with regard to that voucher system? Are you following me?
Dr. Boyer-Patrick. You know, I am, and I guess my concern
was that this is a term that everyone is throwing out there,
faith-based. I'm not always certain what that means. What I
feel is if a person needs help--and not every person needs help
on the same level. Some person might be using marijuana
chronically, and we know that with some of the drugs, you don't
need detox. But if a person walks in and needs detox and they
get a voucher, if there is a good program for detoxification
that is run by a secular or a faith-based, wherever there is a
bed, that's where they need to go. A person might just need
long-term partial, residential. It may be run by a secular
organization or faith-based organization. Wherever there is
availability, if the staff is credentialed, licensed, and there
is a way of tracking outcomes, and they have a good program, to
be quite frank with you, it doesn't matter to me if it's faith-
based or secular as long as the person needing the help gets
the help they need.
Mr. Cummings. The first part of what you just said is the
piece I'm trying to get to. If it--and I'm trying to figure
out, see, when I look at my church effort, I feel that that's
more of a social----
Dr. Boyer-Patrick. That is a support system.
Mr. Cummings. Right. Right. On the other hand--but they do
have some volunteer professional-type people.
Dr. Boyer-Patrick. But if a person in Baltimore needs
heroin detox, they're not going to go to your church first,
because that's not where they're going to get the Buprenex.
That's the point. So they still have to go someplace where they
can get the detoxification services, and then you need the
adjunctive services.
So the question is what is the voucher going to cover, the
adjunctive services or the acute services? And it depends on if
it's alcohol, cocaine. Certainly with crack cocaine, you may
not need detox, or marijuana you're not going to need detox,
but if someone who is coming off of alcohol withdrawal goes to
a faith-based organization that does not have the credentials
to do detox, that person will die. That's the issue.
Mr. Cummings. The voucher system, as I understand it,
there's sort of an entry--there's an entry point where somebody
does an evaluation, and in that evaluation process I assume
that some type of treatment plan is put together. That's what
would normally be done for almost anybody; is that right?
Dr. Boyer-Patrick. That is correct, but so often, as we
know in the city of Baltimore, which is where there is a great
problem, with the majority of people being uninsured and they
need services, they end up in the emergency room, and they go
to places like the psychiatric floor to get what they need.
Then they come out, and they don't get put into the adjunctive
type of services that is going to assure success of recovery.
You're just putting a Band-Aid on what the problem is.
And so what is the voucher program going to do, just offer
detox or offer a full continuum of care? And how much money are
you going to spend for each time, and who's going to determine
that?
Mr. Cummings. Thank you.
Mr. Souder. I think that you've raised a number of things,
but it's really important to understand that there is an irony
to the debate that we're going through, and I want to share a
couple thoughts as we wind up this hearing, because we're going
to be evolving this over the next year as we debate these
different programs.
Two friends of mine, Bob Whitson and Glen Lowery, got in an
argument 15 years ago when I was a staffer on an elevator away
from the general public, of which is probably the argument
we're having here right now. Bob told Glen that he had become
too establishment and was using data and science to masquerade
a lot of the problems that were really human and psychological,
and that Glen's approach was white establishment and he was
buying into the way things did it, which excluded a lot of the
grassroots programs which were actually most effective in the
inner cities. Glen told Bob that he was too enamored of
grassroots people who didn't necessarily want to have the same
accountabilities as everybody else, and that while there was a
truth to that, there needed to be some measurements.
The irony here is that with President Bush's program and
people like myself advocating this, most of these programs
aren't going to be in our Republican districts. Most of the
people who are seeking these grants that we're defending right
now are grassroots organizations who predominantly are
Democrats, who are predominantly in Democratic districts.
I have looked at this for a long time, and I believe
passionately that somewhere in here we've got to figure out
this balance between people who come in and say, I can reach
out and touch people and change their lives, but I don't know
all of the science rigmarole, I don't have a college degree,
but what I am is passionately involved with my neighbors, and I
can get them off and move them, because you say a nonscientific
thing, and that is when people want to get off, that's not
scientific, and therefore some groups may be more effective
than establishment centers at moving people to that first step.
Furthermore, while there may be some health points, I
grant, where the detox or the addiction has gotten so great
that there's a physical endangerment, the truth is much of this
is psychological, and that, in fact, I have talked to multiple
heroin dealers and--addicts and coke addicts who went straight
off and didn't get through detox and have been off for 20
years. Now, the problem is that what makes some individuals
able to do that and others not, and how do we have some kind of
accountability standard that says, OK, you're able to do it
here, but this person, when they try it, dies? And it's almost
like what we've done is we have a risk-averse system that
doesn't take some of the gambles with it, but we don't have
some of the dramatic failures. But I feel, and many others,
that we've missed these little grassroots organizations.
I don't know whether the ranking member wants to go in with
me, but I have threatened that--this is Bob Whitson's idea.
I've threatened to put this in when I worked for Dan Coats. We
stuck it in a couple of model bills, and that is a ZIP code
test, because, you know, one of the most effective things is
that if one-third of these dollars went to people who actually
lived in the ZIP code of the people they are serving, maybe
two-thirds, because part of this is that we get out of the
neighborhoods where people are. When we look at these dramatic
urban center programs, it's because the people are there. The
problems just don't occur 9 to 5. They occur at night. The
followup programs are there. They see the people in their
neighborhoods.
And the question is how do we get dollars into some of
these programs that are in these areas that are people-based,
that are active there, and much of which in the minority
communities are oriented around the churches? How do we do
that, and how do we meet the scientific advances? How do we be
fair to those programs that have been working before that reach
large populations, and they have other assets and strong
families, and at the same time reach our high-risk populations
that need a different approach, because quite frankly, it's not
working overall in the urban centers, and we have some zones
that are in danger of being left behind in America while the
rest of America deals with it.
And I don't believe there's some kind of malicious goal
here to this treatment program or faith-based, that the goal
here is to give it to Jerry Falwell and Pat Robertson. The goal
here is to try to figure out how to advance the field. And it's
not a political gimmick, because if it was, we'd be trying to
give it to the suburbs, quite frankly, as Republicans, or rural
areas. This is a different type of phenomenon, but it's going
to be very difficult to work through, and I very much
appreciate your passion and your years of dedication to it, and
you've been a very articulate spokesman today, and I'm sure
we'll hear from you in the future.
Anything else you want to say in conclusion?
Dr. Boyer-Patrick. In conclusion, what I wanted to say was
you are absolutely right about the grassroots, and many of the
grassroots are nonfaith-based, and many of them are. And I
think it would be a mistake to just make the faith-based issue
a big political issue. I think that there are many programs in
the churches that do outstanding work, without which we could
not be where we are today.
So my only concern is that it was the drug czar who brought
up the issue of measurement and outcomes, and a lot of these
little faith-based programs that do good work don't have the
money to do the measurement and outcomes, so how do you even
know how good they are? And I'm saying if that's where you're
going to go to determine who gets the money, make sure everyone
is on the same playing field, because somebody might be doing
good work, you just don't know about it. But I appreciate the
opportunity to come here.
Mr. Cummings. I just have one question, and I think the
chairman raised a real excellent issue about how do you find in
your field that faith-based organizations are often a major
part of getting a person to that point, like he said, where
they even want to do something about their problem? Do you find
that to be the case?
Dr. Boyer-Patrick. Yes. I find that to be the case, and not
only that, but some of the faith-based organizations, some of
them, because of the fact that they're not in the Federal loop
or State loop, have private funders, and so there they might be
able to offer more longer-term or different types of treatment
that are not held to the same sort of standards. I think that
the only concern is that you don't want a lot of people coming
up just to try to get the money because they are faith-based,
and I think that is what the big fear is, because we've had
this problem before.
But, yes, there are many good, effective programs out there
that are faith-based, and many times the minister is the first
person that the wife will call and say, you know, we have a
problem at home. And that's where the entree is. But the issue
is once you have that entree, to make sure that person gets to
the right place for treatment, and when they come out, they
have that network of services available to keep them clean and
sober. There's no magic to it. It's hard work.
Mr. Cummings. We really do appreciate you being here. Thank
you.
Dr. Boyer-Patrick. Thank you, Mr. Cummings.
Mr. Souder. Thank you very much to all our witnesses today
and to the Members who participated, and with that, our hearing
is adjourned.
[Whereupon, at 12:45 p.m., the subcommittee was adjourned.]
[The prepared statements of Hon. Doug Ose and Hon. C.A.
Dutch Ruppersberger, and additional information submitted for
the hearing record follows:]
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