Coalitions are formed in communities throughout the United States when local institutions, policymakers and residents join together in a voluntary alliance to identify problems such as underage drinking or prescription and over-the-counter medicine abuse. After a careful analysis of root causes and local conditions, members develop and collectively carry out comprehensive strategies to help remedy the identified problem.

Coalitions generally utilize a public health approach rather than provide direct support to a limited number of individuals. They employ advocacy strategies and create political will. Coalitions organize and mobilize locally but frequently join with other likeminded groups to bring about change on the state or national level. Recently, many local coalitions mobilized to support the substance abuse and mental health parity bill, which was signed into law on October 3, 2008.

Improving the way services are financed is a tactic employed by coalitions to help reduce an identified problem. Decisions regarding financing strategies are made strategically based on the larger aim of the coalition. For example, if the coalition’s aim is to identify substance use disorders early and reduce the need for costly, late-stage treatment, they might organize influential community members to convince the local hospital board to require screening, brief intervention and referral for treatment (SBIRT) in the emergency room.

There are five principal ways that coalitions employ financing strategies to reduce the substance use in their communities.
Expand funding: Funding to expand or enhance coalition supported activities is sought from external sources such as local, state or federal sources. For example, coalitions have spearheaded the creation and institutionalization of juvenile drug court programs through federal grants and local matching funding from the justice system. And, they have convinced local policy makers to provide funding to continue the program once it has demonstrated success.

Better utilization of existing funds: By identifying underutilized or misdirected programs or activities, coalitions have helped to channel resources into more productive areas. For example, coalitions have successfully argued that local asset forfeiture funding dedicated to drug supply reduction should be spent on both prevention and enforcement activities.

Improved coordination of funding streams: Coalitions reduce duplication and fragmentation; promote efficiencies and coordinate functions across agencies. Many coalitions have, for example, identified all the local funding spent for substance abuse prevention through the schools, health departments, local faith and community based organizations and substance abuse agencies. These groups then worked together to create a community substance abuse prevention funding system to maximize the impact of their efforts by streamlining and consolidating funding streams.

Increasing non government funding and in-kind support: Coalitions specialize in tapping into community support by mobilizing residents, businesses, faith and civic partners to contribute time and talent to develop and carry out the coalition’s strategic plan. Local universities contribute staff and students for data collection and create evaluation systems, the business community donates materials and political capital, and residents, parents, and young people are involved as volunteer coalition leaders and change agents.

Moving funding “upstream”: Only a small percentage of public funding is allocated for prevention and early intervention efforts. Coalitions recognize the need to ensure that adequate funding is available to reduce the problems that illegal or excessive use of substances creates for the larger community. Creative funding strategies currently employed include obtaining waivers to spend a portion of state foster care dollars to provide substance abuse treatment to parents to reduce the need for costly foster care placements.

Creative financing solutions devised by coalitions have contributed to the significant expansion of prevention efforts. And, coalitions are frequently the “first responders” to ensure that financing strategies promoted by state and national are adopted to address funding gaps in local communities. By employing a “systems” approach to addressing local substance abuse problems, coalitions have made important contributions to reducing substance abuse in their communities.
 

State Mental Health Agencies (SMHAs) are the state government agencies charged with organizing, delivering, and financing services to persons with severe mental illnesses in every state. Collectively, SMHAs are responsible for the delivery of mental health services to over 6 million persons each year and control over $30 billion in expenditures for this care. The persons served by SMHAs are frequently minorities (31%), unemployed (22% were employed), lack private health insurance (54% receive Medicaid), and often have serious mental illnesses or emotional disturbances (66%).

Because mental health services in America are largely organized at the state level, and every state organizes its mental health system differently, SMHAs’ experiences in financing mental health services provide both a learning opportunity and challenge to the mental health field.

SMHAs report that on average, 54% of mental health consumers have Medicaid paying for at least part of their mental health treatment. However, SMHAs vary widely in the proportion of the persons served who use Medicaid, from a high of 100% of persons served by the Maine SMHA and 88% of persons served in Maryland to 19% of persons served in North Dakota and 23% of persons served in Nebraska.

State general revenue funds remain the largest single source of funding (63%) for SMHAs, but Medicaid has been the fastest growing source of funds for the last 20 years and now accounts for 42% ($12.5 billion). SMHAs vary widely regarding how much they rely on Medicaid for the SMHA-controlled expenditures (from a high of 86% in Washington and 84% in Rhode Island to a low of 2% in Hawaii and 4% in Connecticut.

States vary in how much they use Medicaid Managed Care Waivers to organize the delivery of mental health services.  While some states use Medicaid MC Waivers for almost all Medicaid financed services, other states have no waivers and have not implemented managed care.

The NASMHPD Research Institute, Inc. (NRI) is working with SAMHSA and the SMHAs to identify and track the different financing methods used by states. Working with the new NASMHPD Financing and Medicaid Division, the NRI is updating its state MH Agency Profiles system to better track and identify new financial approaches, the use of Medicaid, and the impact of state and federal parity laws on the public mental health system.  Results from this new compilation will be available in early 2009.

As the discussion above indicates, SMHAs vary widely in how they organize and finance their mental health systems. As a result of this variation, changes in rules for financing mental health services through Medicaid or Medicare, private insurance parity, and redirection of state general fund dollars will have a different impact on each state. However, these variations may also allow SAMHSA and the new Financing Center of Excellence to identify numerous natural experiments in financing of mental health services among the states.

From the Kaiser Family Foundation:

"A new federal rule allows states to charge Medicaid beneficiaries premiums and higher copayments for physicians' services, hospital care and prescriptions drugs, the New York Times reports. The rule, which was published on Tuesday in the Federal Register, implements a law (S 1932) signed by President Bush in 2006.

The rule allows states to implement a sliding scale for premiums and copays, the total of which cannot exceed 5% of a family's income. Under the new rule, states in certain cases can deny care or coverage to Medicaid beneficiaries who do not pay their premiums or their portion of the costs for particular items or services. For Medicaid beneficiaries with incomes at or below the federal poverty level, states can require copays of up to $3.40 for a physician visit or other services. That $3.40 maximum will be updated each year in accordance with medical inflation. For Medicaid beneficiaries with incomes between 100% and 150% of the poverty level, states can require beneficiaries to contribute up to 10% of what the state pays for a service. States can require beneficiaries with incomes above those levels to contribute up to 20% of what states pay for a service. The new rule allows states to use copays to encourage the use of preferred brand-name drugs and to discourage the use of emergency departments for primary care."

Full story: http://www.kaisernetwork.org/daily_reports/rep_index.cfm?DR_ID=55798

From the Kaiser Family Foundation:

"President Obama and House Democrats "embrace the creation of a ... 'comparative effectiveness' entity that will do research on drugs and medical devices" -- similar to the National Institute for Health and Clinical ExcellenceAmerican Enterprise Institute, writes in a Wall Street Journal opinion piece. While Obama and House Democrats "claim that they don't want this to morph into a British-style agency that restricts access to medical products based on narrow cost criteria, ... provisions tucked into the fiscal stimulus bill betray their real intentions," according to Gottlieb."

Full story:  http://www.kaisernetwork.org/daily_reports/rep_index.cfm?DR_ID=5654

By investing in substance abuse treatment, employers can reduce their overall costs. Substance use disorders cost the nation an estimated $276 billion a year, with much of the cost resulting from lost work productivity and increased healthcare spending. Given that 76 percent of people with drug or alcohol problems are employed,2 employers have a major stake in ensuring that employees have access to substance abuse treatment.

Full Report:  http://csat.samhsa.gov/IDBSE/employee/SaveMoneybyAssuringAccesstoServices-wpb1.pdf