Mr. Chairman, Members of the Subcommittee, thank you for the opportunity to
provide testimony on the reauthorization of the Substance Abuse and Mental
Health Services Administration. SAMHSA was created in 1992 as a public health
agency in recognition of the need for Federal leadership in improving the
quality and availability of substance abuse prevention, addiction treatment and
mental health services. SAMHSA has successfully provided that leadership for
almost five years now.
In the area of substance abuse, we welcome the leadership and support of the
Director of the Office of National Drug Control Policy (ONDCP), General Barry
McCaffrey. SAMHSA and ONDCP staff are working well together to ensure
coordination of Federal demand reduction efforts and to achieve the goals of
the President's National Drug Control Strategy. Our programs are in concert with
the National Strategy.
We also appreciate the work of our State partners and the organizations
representing the State agencies which are responsible for substance abuse and/or
mental health services, the National Association of State Alcohol and Drug Abuse
Directors (NASADAD) and the National Association of State Mental Health Program
Directors (NASMHPD). Their efforts have helped guide SAMHSA as it has fulfilled
its mission over the past five years. And we appreciate the assistance we have
received from other organizations who have supported this agency and helped it
exercise its leadership role.
With the Subcommittee's help we are proposing to take SAMHSA in some new
directions to meet the challenges of the 21st century. I will begin with a brief
overview of our programs and the status of substance abuse prevention and
treatment and mental health services in America. Next, I will outline the
details of our proposals. Finally, I will discuss how these proposals will
ensure that SAMHSA continues to provide leadership for the Nation's substance
abuse prevention, addiction treatment and mental health service systems.
At SAMHSA, we work to achieve our mission in partnership with other Federal
agencies, States and counties, communities and employers, consumers and
families, advocates and associations, and health professionals through a number
of funding streams and programs. In particular, SAMHSA administers the Substance
Abuse Prevention and Treatment Block Grant and the Community Mental Health
Services Block Grant to the States. SAMHSA also administers the Children's
Mental Health Services Program, the Protection and Advocacy Program, and the
Projects for Assistance in Transition from Homelessness program (PATH). Through
our data collection efforts, SAMHSA serves as a national authority on the
prevalence and incidence of drug use and abuse, addiction treatment capacity and
services delivered, mental health epidemiological data on adults and children
and data on mental health providers and services. And, SAMHSA's discretionary
grant program is focused on increasing the use of proven practices through
"Knowledge Application" and increasing behavioral health system capacity by
improving efficiency and effectiveness of services through "Knowledge
Development". Given this approach, we call our discretionary grant program our
Knowledge Development and Application or KD&A program.
Over the past five formative years for SAMHSA, each of these programs and
funding streams have evolved to meet a host of changes and challenges. A
confluence of deficit reduction, government streamlining, increased
accountability and emphasis on outcome measures, devolution of Federal
responsibilities to States, and a revolution in behavioral health care service
delivery have resulted in an opportunity to propose creative, new approaches for
achieving SAMHSA's mission.
At the same time, the Nation's leading indicator on drug abuse, SAMHSA's
National Household Survey on Drug Abuse, has shown that marijuana use among the
Nation's youth is on the rise and our children are trying drugs at increasingly
younger ages. Yet, in a tribute to successful prevention and treatment efforts,
overall adult rates of illicit drug use in the United States have been cut in
half from the peak in 1979 and remained level since 1992.
If there is one thing we have learned from the recent increase in youth drug
use it is that preventing and reducing drug abuse requires a long-term
sustained commitment of Federal, State and community leadership, as well as
resources and the development of creative new ideas. Our past work has shown we
cannot focus on just one drug alone. Starting early in life, each new generation
needs to be immunized and receive "booster shots" against all forms of substance
abuse -- from methamphetamine to marijuana and from alcohol to tobacco.
Today's social trends make this generation of youth even more vulnerable
than those in the past. The proponents of drug legalization are better organized
than ever before; kids report drugs are easily obtained; and the perception of
harm of drug use is on the decline among youth. For the first time ever, we're
facing a generation of youth many of whose well-educated parents experimented
with marijuana in their own youth. Therefore our problem is made even more
difficult because these parents may be uncomfortable telling their own children
not to use marijuana.
The good news is that SAMHSA's past investments in substance abuse
prevention demonstration grants have produced strategies that directly
counteract some or all of these national social trends. In short, we know what
prevention strategies work. Successful programs are comprehensive and take
advantage of key opportunities to provide youth - early on in life - with
positive messages, role models and opportunities to learn and achieve. The
programs that have employed these strategies have shown positive long-term
effects and cost savings. We are now working on ways through our KD&A program
and block grant to achieve wider adoption of these strategies.
Another area where SAMHSA is making a difference is in the field of
addiction treatment. Last fall, we released the preliminary findings of the
National Treatment Improvement Evaluation Study (NTIES), a five-year study on
the impact of drug and alcohol treatment on over 5,000 clients treated in
substance abuse treatment programs funded by SAMHSA. In a comparison of
behaviors a year before and a year after drug abuse treatment, the rate of
respondents reporting marijuana use declined 50 percent, cocaine use declined 55
percent, crack use declined 51 percent, and heroin use declined 46 percent. The
study also noted large reductions in criminal behavior -- the rate of
respondents selling drugs and committing violent crime declined by 78 percent.
These results are from our most under served and vulnerable populations whose
drug problems tend to be more severe and who have few social supports to help in
their recovery.
Addiction treatment is effective, it improves lives and saves resources
across a broad spectrum of public sector programs. For example, a California
study of treatment effectiveness indicated that for every dollar invested in
treatment the public incurred a return of 7 dollars of savings from reducing
criminal justice, health care, and welfare costs. A similar study in Oregon
found for each dollar invested in treatment there was more than a 5 dollar
return in savings. Unfortunately, the problem is that almost half of the 3.5
million people in serious need of treatment for drug dependence, do not receive
treatment. Through our KD&A program we are working on developing cost saving
strategies that can potentially increase the capacity to provide services-and at
the same time improve the quality of these services.
In the delivery of mental health treatment, we face similar challenges.
Appropriate mental health services can prevent problems from compounding and
promise recovery for many people who have serious mental illness. Indeed, 80 to
90 percent of those who experience depression respond quickly to treatment.
Medications and therapy can help up to 80 percent of those diagnosed with
bipolar disorder, and with proper medication, 80 percent of people diagnosed
with schizophrenia can be relieved of acute symptoms and move beyond illness to
lead productive lives. Yet, despite the many advances in mental health
treatment in America, we know that services are not reaching all those who need
them. Only one fourth of the more than 50 million Americans who experience a
mental disorder in any given year receive treatment. While the President's and
Congress's support of the law that requires insurance companies to have the same
annual and life time limits for mental health services as they do for primary
health care will certainly help, there are still a number of barriers to access
that must be addressed -- different premium levels, inpatient and outpatient day
and visit limitations that are quite different than those for medical and
hospital care, the stigma associated with mental illness, lack of information in
some communities on effective treatment and service approaches. In addition,
the change that was made on annual and life time limits does not apply to
substance abuse. SAMHSA is working in partnership with States, communities,
service providers, consumers and families to address service and information
gaps and improve system performance.
Addressing the needs of people with co-occurring disorders is another
challenge. In addition to the prevalence of drug use, SAMHSA's Nation Household
Survey on Drug Abuse shows a clear relationship between mental health and
substance use, abuse and dependence. Adolescents with psychosocial problems are
more likely to use cigarettes or engage in "binge" drinking and much more likely
to use marijuana than those with little or no indication of mental health
problems. Adults with a major depressive episode, generalized anxiety disorder
or panic attack are about twice as likely to be dependent on cigarettes and
several times more likely to be dependent on illicit drugs than those with none
of these mental disorders.
According to the National Comorbidity Survey, with co- occurring disorders,
the mental disorder often occurs first, during adolescence and 5 to 10 years
before the addictive disorder. While this provides a "window of opportunity" for
targeted substance abuse prevention interventions and needed mental health
services, two-thirds of young people in this country who suffer from a mental
disorder are not receiving the help they need. Without that help these problems
can lead, in addition to alcohol and illicit drug abuse, to school failure,
family discord, violence and even suicide. SAMHSA is leading a vigorous effort
to help families, educators, and others who work with children and adolescents,
as well as young people themselves - to recognize mental health problems and
seek appropriate services. This is a key goal of our Children's Mental Health
Services Program and our Caring for Every Child's Mental Health: Communities
Together initiative.
We know that substance abuse prevention, addiction treatment and mental
health services improve lives, strengthen families and increase productivity,
yet needs exceed our national capacity. This fact combined with the evolving
health care system, the changing roles of and relationships between Federal,
State and local governments, and the efforts at deficit reduction all factor
into how SAMHSA plans to continue to execute its mission in the years to come.
One of the most important tools available to SAMHSA for increasing the
capacity to deliver quality services and to implement new findings is the
substance abuse and mental health block grants. We are proposing to transition
these block grants into Performance Partnerships. Our proposal will increase
State flexibility by allowing States to set their own priorities for
expenditures and management of grant funds while improving accountability. We
bring them to you in partnership with the organizations representing State
agencies responsible for substance abuse and mental health services - NASADAD
and NASMHPD. I want to thank Jack Gustafson of NASADAD and Dr. Bob Glover of
NASMHPD and their staffs for their efforts and support in formulating these
proposals.
For example, we propose consolidating 12 required State plan criteria for
the Community Mental Health Services Performance Partnership Block Grant into
five. This will make it easier for the States to complete their plans, reduce
administrative expenditures while still focusing on the important aspects of
community-based mental health services for adults with serious mental illness
and children with serious emotional disturbance.
For the Substance Abuse Prevention and Treatment Performance Partnership
Block Grant, we are proposing to increase flexibility through a reduction in the
number of mandatory requirements and the creation of a conditional waiver
authority for the Secretary of the Department of Health and Human Services for
some provisions such as tuberculosis services, the set aside for pregnant
addicts and mandatoshed in the Federal
Register after completion of the negotiated rulemaking process.
As we transition to Performance Partnership Block Grants, our efforts are
guided by four core principles: 1) We are working with State and local
governments on the basis of a trust relationship and in an open effort to define
shared expectations about program outcomes. 2) The emphasis will be on ultimate
outcomes. Performance measures that identify meaningful outcomes should be the
basis for assessing the success or failure of programs. 3) States or communities
should be given maximum flexibility to adjust programs to local needs and
priorities, consistent with the broad purposes of the authorizing statutes. 4)
The Federal government will continue to provide leadership, vision and the core
resources to enable States and communities to be effective in their management
of programs. Maintaining and enhancing core capacity includes assisting with
high quality data and surveillance systems to meet national and state needs,
infrastructure and the ongoing provision of technical assistance and training.
We are already beginning to work with some States through pilot projects to
identify performance measures, develop data reporting systems and establish a
sound basis for outcome oriented, Federal-State partnerships. Currently, SAMHSA
devotes approximately $56 million annually to data collection in the Substance
Abuse and Mental Health fields combined. It is very clear that the States vary
in their abilityshed in the Federal
Register after completion of the negotiated rulemaking process.
As we transition to Performance Partnership Block Grants, our efforts are
guided by four core principles: 1) We are working with State and local
governments on the basis of a trust relationship and in an open effort to define
shared expectations about program outcomes. 2) The emphasis will be on ultimate
outcomes. Performance measures that identify meaningful outcomes should be the
basis for assessing the success or failure of programs. 3) States or communities
should be given maximum flexibility to adjust programs to local needs and
priorities, consistent with the broad purposes of the authorizing statutes. 4)
The Federal government will continue to provide leadership, vision and the core
resources to enable States and communities to be effective in their management
of programs. Maintaining and enhancing core capacity includes assisting with
high quality data and surveillance systems to meet national and state needs,
infrastructure and the ongoing provision of technical assistance and training.
We are already beginning to work with some States through pilot projects to
identify performance measures, develop data reporting systems and establish a
sound basis for outcome oriented, Federal-State partnerships. Currently, SAMHSA
devotes approximately $56 million annually to data collection in the Substance
Abuse and Mental Health fields combined. It is very clear that the States vary
in their ability to collect and analyze data on cost, organization, human
resources and especially outcomes data. Therefore, to support the modification
of the Block Grants, we are proposing a new authority for grants to States for
data collection and analysis with regard to performance measures including
measures of capacity, process and outcomes. In exchange for new resources States
would agree to work with SAMHSA to develop a minimum set of performance measures
for treatment and prevention programs, and to put in place a system for the
collection and reporting of such information. As a condition of receipt of funds
the States would be required to report back to the Secretary on a core set of
performance measures within two years of an award. We believe such a program
will not only assist States in their outcome measurement efforts, but would also
contribute to the national picture of our progress in mental health and
substance abuse prevention and treatment, and aid us in fulfilling requirements
under the Government Performance and Results Act (GPRA).
The Knowledge Development and Application (KD&A) program also represents a
new approach for SAMHSA's discretionary grant program. Given changing needs and
new national priorities, SAMHSA re-directed the focus of its discretionary grant
program from one of supplementing and building service capacity to a targeted
approach of developing and applying knowledge that will leverage Federal
resources. For example, we are increasing the use of proven practices through
the "Knowledge Application" arm of the program and we anticipate increasing
system capacity by improving efficiency and effectiveness of services through
the "Knowledge Development" arm.
Our priorities for "Knowledge Development" are: "managed care", "early
childhood problems and working families", and "improving community services".
For example, in the area of early childhood and working families, SAMHSA has
launched a Starting Early-Starting Smart collaborative effort. Working with The
Casey Family Program and the Department of Education, SAMHSA is developing new
knowledge, demonstrating what works, and creating collaborative community-based
partnerships to sustain improved primary, mental health and substance abuse
prevention services for children from birth to age 7 and their families or care
givers. SAMHSA initiated the Starting Early-Starting Smart program because so
many social and economic factors impact children's mental health and well being
and their potential for substance abuse. This interagency collaboration will
bring all the available resources to bear on providing coordinated, quality
health care services for children and their care givers. I clearly see this
collaboration as just the beginning of a much needed effort to improve the lives
of our children.
Our priorities for "Knowledge Application" are: "changing systems and
practices" and developing "standards and guidelines." In the category of
"changing systems and practices," SAMHSA has initiated a new approach toward
youth substance abuse prevention that takes advantage of the unique role the
Federal government can play in this nationwide problem. Under our new State
Incentive Grant Program for Community Based Action, the application calls upon
States to develop comprehensive strategies for youth substance abuse prevention.
State plans must account for Federal and State funding streams and programs in
the State, identify gaps and propose how the combined resources will be brought
together and used to reduce youth substance abuse. In particular, the Substance
Abuse Prevention and Treatment Block Grant is an appropriate pool of funds for
the States to draw upon to support this Initiative.
In designing their plans, States may propose their own approaches but will
be offered a menu of effective substance abuse prevention strategies and
programs that are based on scientific research. State plans must include
performance and outcome measures and success will be measured through the
reporting of both baseline and post-program data. Another key component of a
successful application will be the involvement of established community groups.
We see community involvement and action as key to the success of this
initiative. Further, State involvement is critical to our need to coordinate
efforts and leverage Federal resources.
To effectively carry out the transition to the KD&A approach, SAMHSA is
proposing consolidated authorities in substance abuse prevention, addiction
treatment and mental health services. These provisions would replace a number of
current prescriptive and restrictive categorical provisions with programs that
provide increased flexibility with a focus on performance and results. The
consolidated authority will also give us the flexibility to respond to the needs
of the mental health and substance abuse fields.
While the Knowledge Development and Application program and the Performance
Partnership Block Grants remain the largest and most visible of SAMHSA s current
efforts, our proposal continues other SAMHSA activities that are critical to
improving-quality and availability of services. These include: collecting and
analyzing data; developing comprehensive community mental health services for
children and adolescents; developing the first ever "Report Card" generated by
and for consumers of mental health services to gauge accessibility and quality
of mental health services provided through managed care plans; and investigating
incidents of abuse and neglect of individuals with mental illness.
Over the years, our work and the taxpayers' investment in SAMHSA have shown
that substance abuse prevention, addiction treatment and mental health services
can and do work. We also know that investing Federal resources in these areas
make sense. It improves lives, strengthens families, and increases
productivity.
Mr. Chairman, we are committed to continuous improvement in the way SAMHSA
does business and to ensuring that our efforts continue to have a positive
impact on the Nation's prevention and treatment systems. We are requesting not
only reauthorization but some improvements in our authorizing language that will
enhance our ability to have a greater impact on substance abuse and mental
health problems in the U.S. and at the same time demonstrate accountability for
the Federal dollars entrusted to SAMHSA.
It is clear that each new generation of American youth presents us with new
challenges. Each new scientific advance in substance abuse prevention, addiction
treatment and mental health services provides new options. And these options
need to be translated and applied to every day, real-life practices in order to
improve the quality and availability of substance abuse prevention, addiction
treatment and mental health services.
SAMHSA's Knowledge Development and Application program is the Federal tool
specifically designed to make progress and improve services in our Nation's
communities. Our Performance Partnership Block Grants With States are the
vehicles available to leverage adoption of best practices and increases our
capacity to deliver quality services to individuals in need. In short, this is
SAMHSA's unique role in the Federal government.
I'm optimistic and enthusiastic about what the future holds for our ability,
with the Subcommittee's help, to address some of the Nation's most costly and
devastating problems. Again, Mr. Chairman and Members of the Subcommittee,
thank you for the opportunity to appear today. I'll be pleased to answer any
questions you may have.
