Substance Abuse and Mental Health Services Administration (SAMHSA): Agency Overview and Reauthorization Issues
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Substance Abuse and Mental Health Services
Administration (SAMHSA): Agency
Overview and Reauthorization Issues
(name redacted)
Specialist in Health Policy
November 4, 2010
Congressional Research Service
7-....
www.crs.gov
R41477
CRS Report for Congress
Prepared for Members and Committees of Congress
SAMHSA: Agency Overview and Reauthorization Issues
Summary
The Substance Abuse and Mental Health Services Administration (SAMHSA), within the
Department of Health and Human Services (HHS), provides federal funding to support
community-based mental health and substance abuse prevention and treatment services.
SAMHSA awards formula and competitive grants under its authorities in Title V of the Public
Health Service Act (PHSA). The agency also administers the $1.8 billion Substance Abuse
Prevention and Treatment (SAPT) block grant and the $420 million Community Mental Health
Services (CMHS) block grant, both of which are authorized in PHSA Title XIX. SAMHSA’s
funding totaled almost $3.6 billion in FY2010. The agency’s budget increased by 34% from
FY2000 to FY2010. In real (i.e., inflation-adjusted) dollars, however, the funding increase over
that period was only 6%. Funding for SAMHSA’s two block grants, which together account for
62% of the agency’s budget, has grown at a much slower pace than funding for its competitive
grant programs.
SAMHSA was reauthorized in 2000, as part of the Children’s Health Act (P.L. 106-310). The act
amended SAMHSA’s existing authorities to give the agency more flexibility to direct mental
health and substance abuse funding; increased state flexibility to direct the use of block grant
funds, creating several new competitive grant programs to expand mental health and substance
abuse services for children and adolescents; and authorized appropriations through FY2003. It
also added charitable choice provisions that allow faith-based organizations to compete for
SAMHSA substance abuse funding without impairing their religious character. P.L. 106-310
required SAMHSA to submit two reports to Congress, one on providing coordinated care to
individuals with co-occurring mental illness and substance abuse, and the other on efforts to
improve the flexibility and accountability of the block grants.
Comprehensive reauthorization has not occurred since 2000. However, several laws have further
expanded the agency’s programs and activities in suicide prevention, underage drinking, and
prescription drug abuse. The Patient Protection and Affordable Care Act of 2010 (P.L. 111-148)
contained new authorizations for SAMHSA related to depression and behavioral health services
for American Indians and Alaskan Natives, as well as additional provisions related to mental
health and substance abuse.
While reauthorization has not moved out of committee, issues that may be of interest during the
next reauthorization of SAMHSA include increased performance measurement and accountability
for SAMHSA grants and programs, granting specific authority for the Access To Recovery
program that provides vouchers for individuals to seek treatment services, improving the ability
of communities to provide behavioral health services during disaster response, requiring
collaboration between SAMHSA and other federal agencies, increasing SAMHSA’s level of
emphasis on primary prevention, increasing SAMHSA’s role in expanding the number and
diversity of the behavioral health provider workforce, and ensuring fairness of the formula used
to distribute SAMHSA’s block grants.
This report describes SAMHSA’s history, organization, authority, and programs, and analyzes
some of the issues that may be considered by Congress during a reauthorization of the agency.
The appendixes include a table describing SAMHSA’s authorizations and appropriations, a table
with SAMHSA’s funding from FY2000-FY2010, a matrix of SAMHSA’s National Outcome
Measures that aim to evaluate progress on substance abuse and mental health prevention and
treatment indicators, and a list of SAMHSA resources.
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SAMHSA: Agency Overview and Reauthorization Issues
Contents
Introduction...................................................................................................................................... 1
SAMHSA Authorization and Organization ..................................................................................... 2
Center for Substance Abuse Treatment ..................................................................................... 3
Center for Substance Abuse Prevention .................................................................................... 4
Center for Mental Health Services ............................................................................................ 5
Center for Behavioral Health Statistics and Quality.................................................................. 6
SAMHSA Funding........................................................................................................................... 7
SAMHSA Reauthorization in 2000 ................................................................................................. 9
New Authorizations Since 2000 .................................................................................................... 11
The Patient Protection and Affordable Care Act............................................................................ 12
Strategic Direction ......................................................................................................................... 13
SAMHSA Strategic Plan, FY2006-FY2011 ............................................................................ 13
SAMHSA Data Strategy, FY2007-FY2011............................................................................. 14
SAMHSA Strategic Initiatives, 2011-2014 ............................................................................. 14
Current Reauthorization Issues...................................................................................................... 15
Performance Measurement and Accountability....................................................................... 15
Access to Recovery ................................................................................................................. 16
Disaster Response.................................................................................................................... 17
Collaboration with Other Federal Agencies ............................................................................ 18
Focus on Prevention and Early Intervention ........................................................................... 19
Workforce Issues ..................................................................................................................... 20
Block Grant Formula............................................................................................................... 21
History of SAMHSA Block Grants................................................................................... 21
Current Formula ................................................................................................................ 23
Issues Regarding Current Formula.................................................................................... 23
Figures
Figure 1. SAMHSA Funding in Real and Actual Dollars, FY2000-FY2010 .................................. 7
Figure 2. SAMHSA Funding Growth, FY2000-FY2010................................................................. 8
Figure 3. Block Grant Timeline ..................................................................................................... 22
Tables
Table A-1. SAMHSA Program Descriptions, Authorizations of Appropriations, and
Funding....................................................................................................................................... 26
Table A-2. SAMHSA Funding, FY2000-FY2011.......................................................................... 31
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SAMHSA: Agency Overview and Reauthorization Issues
Appendixes
Appendix A. SAMHSA Authorizations and Funding .................................................................... 25
Appendix B. SAMHSA National Outcome Measures................................................................... 32
Appendix C. Useful SAMHSA Resources..................................................................................... 33
Contacts
Author Contact Information........................................................................................................... 33
Acknowledgments ......................................................................................................................... 33
Congressional Research Service
SAMHSA: Agency Overview and Reauthorization Issues
Introduction
The Substance Abuse and Mental Health Services Administration (SAMHSA), within the
Department of Health and Human Services (HHS), is the lead federal agency for increasing
access to behavioral health services. SAMHSA funds community-based mental health and
substance abuse treatment and prevention services and collects information on the incidence and
prevalence of mental illness and substance abuse at the national and state level. These activities
support SAMHSA’s mission to improve the lives of people with substance abuse disorders and
mental illnesses.
SAMHSA funds mental health and substance abuse services through formula and competitive
grants. SAMHSA provides formula funding to states, U.S. territories, and the Red Lake Indian
tribe, while competitive funding is awarded through numerous grant programs to states,
territories, tribal organizations, local communities, and private entities. Under SAMHSA’s
charitable choice provisions, religious organizations are eligible to receive funding in order to
provide substance abuse services without altering their religious character.
SAMHSA’s two largest programs are the $1.8 billion Substance Abuse Prevention and Treatment
(SAPT) block grant and the $421 million Community Mental Health Services (CMHS) block
grant, which account for more than 60% of the agency’s budget in FY2010. The SAPT block
grant provides approximately 40% of the expenses of state agencies responsible for substance
abuse prevention and treatment services.1 By comparison, the CMHS block grant funds on
average 2% of the expenses of state mental health agencies.2 The difference reflects the historical
role federal and state governments have played in funding services in these two areas, with states
providing a much larger portion of mental health funding than substance abuse funding.
SAMHSA also collects data on mental health and substance abuse at the national and state level.
These data provide information on the incidence and prevalence of mental illness and substance
abuse, the availability and utilization of treatment services, and the outcomes of mental health and
substance abuse prevention and treatment services. SAMHSA uses this information to monitor
mental health and substance abuse trends and to help determine how resources should be directed.
In addition, performance and outcome data are used to measure the impact of programs and
interventions.
This report provides an overview of SAMHSA’s organization and programs and includes some
analysis of the agency’s funding over the past decade. It also highlights some of the issues that
may be addressed by Congress when it next considers legislation to reauthorize SAMHSA and its
programs. SAMHSA was last reauthorized in 2000. Authorizations of appropriations for most of
SAMHSA’s grant programs expired at the end of FY2003, though many of them continue to
receive funding. Comprehensive reauthorization of SAMHSA was discussed during the 110th
Congress,3 and reauthorizing legislation was introduced in the 111th Congress.4 Possible
1
National Association of State Alcohol and Drug Abuse Directors, Fact Sheet: Substance Abuse Prevention and
Treatment (SAPT) Block Grant, June 2009, http://www.nasadad.org/resource.php?base_id=1756.
2
NASMHPD Research Institute, Table 27: SMHA-Controlled Mental Health Revenues Dedicated to State Mental
Health Agency Support Programs, by Revenue Source and by State, FY 2008 ( in millions), http://www.nri-inc.org/
projects/Profiles/RevExp2008/T27.pdf.
3
SAMHSA, Minutes of the 44th Meeting of the SAMHSA National Advisory Council, September 2008.
4
The SAMHSA Modernization Act of 2010 (H.R. 5466).
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reauthorization issues include increased performance measurement and accountability for
SAMHSA grants, granting specific authority for the Access to Recovery program, improving the
ability of communities to provide behavioral health services during disaster response, requiring
collaboration between SAMHSA and other federal agencies, increasing SAMHSA’s level of
emphasis on primary prevention, increasing SAMHSA’s role in expanding the number and
diversity of the behavioral health provider workforce, and ensuring fairness of the formula used
to distribute SAMHSA’s block grants. This report will be updated as warranted by legislative and
other developments.
SAMHSA Authorization and Organization
SAMHSA and most of its programs and activities are authorized under Title V of the Public
Health Service Act (PHSA). The SAPT and CMHS block grants are separately authorized under
PHSA Title XIX Part B. SAMHSA has authority to administer several specific formula and
competitive grant programs to support mental health and substance abuse prevention and
treatment services, as well as general authorities for activities in these areas. Appropriations for
the agency were reauthorized in 2000, as part of the Children’s Health Act.5 The act amended
SAMHSA’s existing authorities under Title V, added several new authorities, and authorized
appropriations through FY2003. Congress has not taken up comprehensive reauthorization
legislation since 2000, though it has added some new authorities to Title V and otherwise
expanded the agency’s programs and activities (see “New Authorizations Since 2000” below).
PHSA Title V authorizes SAMHSA programs under three centers: the Center for Mental Health
Services (CMHS), the Center for Substance Abuse Treatment (CSAT), and the Center for
Substance Abuse Prevention (CSAP). The PHSA also directs SAMHSA to conduct data
collection and analysis activities related to mental health and substance abuse. These activities are
centrally coordinated in the Center for Behavioral Health Statistics and Quality.
SAMHSA funds competitive and formula grant programs. While the majority of SAMHSA
programs provide funding through a competitive grant process, together these programs account
for only one-third of the agency’s budget. The five formula grants—primarily the two block
grants—account for the other two-thirds of SAMHSA’s budget. This mix of funding provides
flexibility at both the federal and state levels. The formula block grants allow states the flexibility
to allocate funding to address specific issues and populations within their jurisdictions, but they
do not allow funding levels to be easily adjusted based on changing levels of need due to fixed
statutory funding formulas (see “Block Grant Formula” below). By comparison, competitive
grant programs are generally issue-specific. These grants allow SAMHSA to allocate funding for
a particular issue, such as suicide prevention, to areas and populations with the greatest need.
Title V authorizes numerous competitive grant programs, some, but not all, of which receive
funding through the annual appropriations process. For instance, Early Intervention Services for
Children and Adolescents6 and Grants for Emergency Mental Health Centers7 have never received
funds. In addition to the grant programs with specific statutory authority, which are often referred
to as categorical grants, each center also has general authority, called Programs of Regional and
5
P.L. 106-310, Titles XXXI-XXXIV.
PHSA Sec. 514A.
7
PHSA Sec. 520F.
6
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National Significance (PRNS), to fund states and communities to address priority substance abuse
and mental health needs. PRNS authorizes the center to fund projects that (1) translate promising
new research findings to community-based prevention and treatment services; (2) provide
training and technical assistance; and (3) target resources to increase service capacity where it is
most needed. Each center funds several grant programs that were created under its general (i.e.,
PRNS) authority. Examples of such PRNS programs include the Access to Recovery program and
the Strategic Prevention Framework, described below.
Most SAMHSA programs are administered by one of the three centers and focus on mental
health, substance abuse prevention, or substance abuse treatment. This structure encourages the
development of programs that fit within a center, and can make it more difficult to implement
programs that focus on both mental health and substance abuse. Several cross-cutting programs
receive support separately from all three centers, including the National Registry of Evidencebased Programs and Practices, the SAMHSA Health Information Network, the Minority AIDS
Program, and the Minority Fellowship Program. To better address cross-cutting issues, SAMHSA
has also created connections between centers for programs with both mental health and substance
abuse components. For instance, the co-occurring state incentive grant, which supports
improvements to infrastructure and capacity for treating individuals with both mental health and
substance abuse conditions, is administered by both CMHS and CSAT.
A brief description of each center follows, including a list of significant programs. As noted
above, some programs are specifically authorized, and others are created and funded under the
general PRNS authority. Table A-1 in Appendix A at the end of the report includes a description
of SAMHSA’s program authorities—including current funding and appropriations history—
within each of SAMHSA’s centers. In addition, Appendix C includes links to SAMHSA websites
with additional information on the agency’s centers, programs, and grants.
SAMHSA History
In 1974, the Alcohol, Drug Abuse, and Mental Health Administration (ADAMHA) was established by the
Comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment, and Rehabilitation Act Amendments (P.L. 93282). ADAMHA was created to provide federal funding to states for substance abuse and mental health treatment
services. In addition, ADAMHA was designated as the parent agency for three existing research agencies—the
National Institute of Mental Health (NIMH), the National Institute on Drug Abuse (NIDA), and the National Institute
on Alcohol Abuse and Alcoholism (NIAAA). Prior to the creation of ADAMHA, these research institutes were part
of the National Institutes of Health (NIH).
In 1992, the ADAMHA Reorganization Act (P.L. 102-321) moved the three research institutes back to the NIH and
renamed the agency SAMHSA to reflect its focus on funding community-based services. While the original mission of
NIMH included programs for educating and training clinical personnel and for providing leadership to enhance the
quality of treatment services, SAMHSA took on these responsibilities and NIMH retained its research activities.
Center for Substance Abuse Treatment
CSAT is authorized to develop, evaluate, and implement effective substance abuse treatment
programs, and to improve the quality of services and access to services.8 CSAT administers the
formula-based SAPT block grant, as well as a much smaller formula grant for prescription drug
monitoring. The center also administers several competitive grant programs that focus on
treatment and recovery support services, homeless individuals, early detection, and criminal
8
PHSA Sec. 507.
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SAMHSA: Agency Overview and Reauthorization Issues
justice populations. Included below are brief descriptions of significant programs within CSAT
that account for most of the center’s funding. See Table A-1 for a full list of authorized programs
and funding within CSAT.
•
Substance Abuse Prevention and Treatment Block Grant: Formula grants to states
to plan, carry out, and evaluate activities to prevent and treat substance abuse.
•
Access to Recovery (ATR): Grants to states and tribal organizations to evaluate
individuals with substance abuse issues and provide vouchers for treatment and
recovery support services that can be redeemed with approved providers. This
program is discussed below in the “Access to Recovery” section.
•
Screening, Brief Intervention, and Referral to Treatment (SBIRT): Grants to states
and tribal organizations to integrate substance abuse screening, brief intervention,
referral, and treatment services within general medical and primary care settings
in order to identify individuals with or at risk for a substance abuse disorder.
•
Treatment Drug Courts: Grants to adult, juvenile, and family drug courts and
providers to fund substance abuse treatment, assessment, case management, and
program coordination for those referred by the drug courts.
•
Grants for the Benefit of Homeless Individuals: Grants to organizations to
provide services for homeless individuals with a substance use disorder or who
have co-occurring substance abuse and mental health disorders.
•
Minority AIDS: Grants to community-based organizations to provide substance
abuse treatment and related HIV/AIDS services targeting high-risk substance
abusing populations.
•
Targeted Capacity Expansion: Grants to states, local governments, and tribal
entities to expand or enhance a community’s ability to respond to a specific, welldocumented substance abuse capacity problem.
Center for Substance Abuse Prevention
CSAP is authorized to support efforts to prevent substance abuse through public education,
training, technical assistance, and data collection.9 The center provides states with grants to
support their strategic planning activities for substance abuse prevention, and maintains a registry
of evidence-based prevention practices. It also administers competitive grant programs that focus
on improving and expanding community-based substance abuse prevention activities, and
preventing underage drinking, fetal alcohol disorders, and substance abuse in high-risk
populations. Finally, CSAP administers a 20% prevention set-aside from the SAPT block grant.
Included below are brief descriptions of significant programs within CSAP. See Table A-1 for a
full list of authorized programs and funding within CSAP.
•
9
Substance Abuse Prevention and Treatment Block Grant (20% prevention setaside): Formula funding to support six primary prevention strategies: information
dissemination, education, alternatives, problem identification and referral,
community-based processes, and environmental strategies.
PHSA Sec. 515.
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•
Strategic Prevention Framework: Grants to states, territories, and tribal
organizations to implement a public health approach to substance abuse
prevention through needs assessment, capacity building, strategic planning,
evidence-based practices, and program evaluation.
•
Sober Truth on Preventing Underage Drinking (STOP): Grants to community
based coalitions for underage-drinking programs in communities, and funding for
the underage drinking prevention media campaign.
•
Minority AIDS: Grants to organizations to support the delivery and sustainability
of substance abuse and HIV prevention services in minority communities.
•
Fetal Alcohol Spectrum Disorder Center of Excellence: Identifies and
disseminates information about innovative techniques and effective strategies for
preventing fetal alcohol spectrum disorder.
Center for Mental Health Services
CMHS is authorized to prevent mental illness and promote mental health by providing funds to
evaluate, improve, and implement effective treatment practices; address violence among children;
provide technical assistance to state and local mental health agencies; and collect data.10 CMHS
administers the formula-based CMHS block grant, as well as two other smaller formula grant
programs that fund advocacy activities and homeless services. The center also administers several
competitive grant programs focusing on children’s mental health, youth violence prevention,
support for the homeless, suicide and other prevention services, and mental health care system
transformation. Included below are brief descriptions of significant programs within CMHS. See
Table A-1 for a full list of authorized programs and funding within CMHS.
10
•
Community Mental Health Services Block Grant: Formula grants to states and
territories to support community mental health services for adults with serious
mental illness and children with serious emotional disturbance.
•
Protection and Advocacy for Individuals with Mental Illness (PAIMI): Formula
grants to independent protection and advocacy agencies identified by states and
territories to protect the mentally ill from abuse, neglect, and violations of their
civil rights.
•
Projects for Assistance in Transition from Homelessness (PATH): Formula grants
to states and territories to provide outreach, mental health, and other support
services to homeless people with serious mental illness.
•
Services in Supportive Housing: Grants to provide mental health and related
wrap-around services for individuals and families experiencing chronic
homelessness in coordination with existing housing programs.
•
Children’s Mental Health Services: Six-year grants to implement, improve, and
expand systems of care to meet the needs of children with serious emotional
disturbances and their families.
PHSA Sec. 520.
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•
National Child Traumatic Stress Network: Funds a national network of experts to
collaboratively develop and promote effective community practices for children
and adolescents exposed to traumatic events.
•
Safe Schools/Healthy Students: Grants to local educational agencies through the
Department of Education to implement programs and services that focus on
promoting healthy childhood development and preventing violence and alcohol
and other drug abuse.
•
Youth Suicide Prevention: Programs include suicide prevention grants to states,
tribal organizations, and institutions of higher learning; a suicide prevention
hotline; and a national suicide resource center.
•
Mental Health System Transformation Grants: Grants to local communities to
promote the adoption and implementation of permanent transformative changes
in how communities manage and deliver mental health services.
Center for Behavioral Health Statistics and Quality
The Center for Behavioral Health Statistics and Quality (CBHSQ), formerly the Office of Applied
Studies (OAS), collects and analyzes national and state-level data on mental health and substance
abuse, including information on the incidence of substance abuse and mental health conditions in
the United States, and the characteristics of those who suffer from these problems.11 CBHSQ also
collects information on substance abuse prevention and treatment providers, including the cost,
quality, and effectiveness of services. This information is collected using a variety of surveys,
surveillance systems, and other studies, which are summarized below.
11
•
National Survey on Drug Use and Health (NSDUH): Annual survey that collects
data on illicit drug use, non-medical use of prescription drugs, and alcohol and
tobacco use among individuals ages 12 and over. NSDUH is the primary source
of information on the prevalence, patterns, and consequences of alcohol, tobacco,
and illegal drug use in the general U.S. civilian, non-institutionalized population.
•
Drug Abuse Warning Network (DAWN): A public health surveillance system that
provides estimates of the number of drug-related visits to hospital emergency
departments in large metropolitan areas and provides information on drug-related
deaths in 40 metropolitan areas based on medical examiner data.
•
Drug and Alcohol Services Information System (DASIS): This system provides
information collected through the following three components:
•
Treatment Episode Data Set (TEDS): Data submitted by states on the
demographic and substance abuse characteristics of admissions to
facilities that are licensed or certified by the state substance abuse agency
to provide treatment services.
•
National Survey of Substance Abuse Treatment Services (N-SSATS):
Annual survey that collects data on private and public alcohol and drug
abuse treatment facilities and services across the country.
PHSA Sec. 505 authorizes SAMHSA’s data collection activities.
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•
Inventory of Substance Abuse Treatment Services (I-SATS): A listing of
public and private substance abuse treatment facilities in the United
States.
SAMHSA Funding
SAMHSA’s budget totaled $3.563 billion in FY2010, and the agency’s budget request for FY2011
would add an additional $111 million to that total. Substance abuse activities account for 69% of
the funding in SAMHSA’s budget, while 28% of the funding is for mental health activities. The
remaining 3% of funding supports program management. For both substance abuse and mental
health activities, the two block grants constitute the largest portion of funding, and together made
up 62% of SAMHSA’s budget in FY2010. Table A-2 in Appendix A shows SAMHSA funding
for the period from FY2000 through the FY2011 budget request, including funding totals for
mental health and substance abuse activities and funding for major programs.
Figure 1 compares SAMHSA’s funding from FY2000 through FY2010 before and after adjusting
for inflation. While actual SAMHSA funding has increased most years since FY2000, the trend
line for inflation-adjusted agency funding is relatively flat between FY2000 and FY2010. Overall,
the agency’s funding in actual dollars increased by 34% over the period FY2000-FY2010. In real
(i.e., inflation-adjusted) dollars, however, the funding increase over that period was only 6%.
Figure 1. SAMHSA Funding in Real and Actual Dollars, FY2000-FY2010
(dollars in billions)
4.0
3.5
3.0
3.0
2.5
2.7
2.9
3.1
3.2
3.0
3.0
3.4
3.4
3.1
3.0
2.7
3.3
3.3
2.8
2.8
3.6
3.5
3.4
2.8
2.8
2.7
2.0
1.5
1.0
Actual Dollars
0.5
Real Dollars (2000)
0.0
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
Source: Prepared by CRS using SAMHSA budget justification documents.
Notes: Real dollar amounts have been calculated using the U.S. Department of Labor’s Bureau of Labor Statistics
Consumer Price Index (CPI) inflation calculator.
Within SAMHSA, funding growth since FY2000 varies significantly among programs. Figure 2
below shows the percentage increase in SAMHSA’s funding from FY2000 to FY2010, including
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SAMHSA: Agency Overview and Reauthorization Issues
funding for specific programs, program areas, and the agency’s overall budget. The dotted line
shows the 27% increase in funding needed to keep pace with inflation over that 10-year period.
Programs with funding increases under the dotted line have experienced a decline in real (i.e.,
inflation-adjusted) funding since FY2000. Overall, CMHS-administered mental health programs
have grown at more than twice the rate of substance abuse programs, which are administered by
CSAT and CSAP. In addition, program management funding, which supports SAMHSA staff, has
grown more than funding for mental health and substance abuse programs.
On the program level, funding for both the mental health and substance abuse block grants has
increased very little since FY2000, with growth rates below the 27% needed to keep up with
inflation. In contrast, programs under the PRNS budget lines, which include all competitive grant
programs except Children’s Mental Health, have received the largest funding increases. 12 From
FY2000 to FY2010, mental health PRNS grew by 166% and substance abuse treatment PRNS
grew by 112%. Substance abuse prevention PRNS grew much less, increasing by 37% from
FY2000 to FY2010. Unlike the block grant funding, which is largely directed by states, the PRNS
funding primarily supports priorities identified by SAMHSA. After the PRNS funding, the PATH
formula grant grew the most, with a 110% increase in funding from FY2000 to FY2010. See
Table A-2 in Appendix A for funding levels by program area for each year.
Figure 2. SAMHSA Funding Growth, FY2000-FY2010
180%
166%
160%
140%
112%
120%
110%
100%
73%
80%
59%
60%
40%
44%
37%
34%
46%
25%
18%
12%
20%
0%
All
SAMHSA
All SA
All MH
Program
Mgmt
Overall
SA Block
Grant
SA
SA
Trtmnt Prevention
(PRNS) (PRNS)
MH Block PATH Protection MH
Children’s
Grant Homeless
and
(PRNS)
MH
Advocacy
Substance Abuse
Mental Health
27% growth needed to maintain FY2000 funding level in real (inflation adjusted) dollars
Source: Prepared by CRS using SAMHSA budget justification documents.
Notes: Inflation calculated using the U.S. Department of Labor’s Bureau of Labor Statistics Consumer Price Index
(CPI) inflation calculator.
12
SAMHSA’s PRNS budget lines include competitive grant programs created under general (i.e., PRNS) authority and
competitive grant programs with specific PHSA authorizations.
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SAMHSA Reauthorization in 2000
As already noted, SAMHSA was last reauthorized in 2000. The reauthorization language was
incorporated in the Children’s Health Act of 2000 (see text box below).13 The act amended
SAMHSA’s existing authorities under Title V, added several new authorities, and authorized
appropriations through FY2003. Congress has not taken up comprehensive reauthorization
legislation since 2000, though it has enacted a number of laws that have added new authorities to
Title V and otherwise expanded the agency’s programs and activities (see “New Authorizations
Since 2000” below). The following key provisions were included in the 2000 reauthorization,
which
•
increased flexibility for SAMHSA to direct mental health and substance abuse
funding by rewriting and standardizing the general authority (i.e., PRNS) for
each center and eliminating several existing categorical grant programs;
•
increased flexibility for states to direct the use of block grant funds to treat
mental health and substance abuse disorders;
•
added new categorical grant programs, primarily with a focus on expanding and
improving mental health and substance abuse services for children and
adolescents; and
•
added “charitable choice” provisions that allow religious organizations to receive
funding from SAMHSA for the provision of substance abuse prevention and
treatment services (see “Charitable Choice” text box below).
The new categorical programs included ones to support community-based prevention and
treatment services for youth at risk due to violence, substance abuse, or mental illness, and to
support services for youth in the justice and child welfare systems. Other SAMHSA programs
created during the reauthorization provide support for homeless individuals and adults in the
justice system with substance abuse and/or mental illness, and authorize funding for the
prevention and treatment of methamphetamine abuse. See Table A-1 for a description of all
authorized programs within SAMHSA.
Additionally, the Children’s Health Act included two sets of provisions related to the use of
restraint and seclusion on residents at certain types of facilities.14 The first set of provisions,15
which apply to hospitals, nursing homes, and other medical facilities that receive federal funding,
specify that restraint and seclusion may only be used to ensure the physical safety of a patient and
can only be implemented under the written order of a physician or other qualified provider.16
These facilities are required to report deaths resulting from restraint and seclusion to the
appropriate agency specified by the Secretary within one week of the death. The second set of
13
P.L. 106-310, Titles XXXI-XXXIV.
Restraint refers to the restricting the movement of a person’s limbs, head or body by the use of mechanical or
physical devices for the purpose of preventing injury to self or others. Seclusion refers to the isolation and containment
of residents who pose an imminent threat of physical harm to themselves or others.
15
PHSA Secs. 591-593.
16
The restraint and seclusion provisions in the Children’s Health Act do not override federal and state laws and
regulations that provide greater patient protection, such as the restraint and seclusion regulations issued in 1999 by the
Health Care Financing Administration (now the Centers for Medicare and Medicaid Services) for hospitals
participating in the Medicare and Medicaid programs (42 CFR 482 Subpart B).
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provisions,17 which applies to communitybased residential treatment centers for youth,
specifies that restraint and seclusion may only
be used in emergencies and to ensure
immediate safety, and it prohibits the use of
mechanical restraints. These facilities are
required to report deaths occurring as a result
of use of restraint to an agency specified by
the Secretary within 24 hours of the death.18
The 2000 reauthorization law also required
SAMHSA to produce two reports for
Congress. The first report, released in 2002, is
on the efforts of the agency and the states to
provide coordinated prevention and treatment
services for co-occurring substance abuse and
mental health problems. In the report,
SAMHSA identified barriers to treatment for
co-occurring disorders, summarized the best
practices for treatment of people with cooccurring disorders, and provided a five-year
plan for improving services for these people.
The plan focused on implementation of best
practices for prevention and treatment of cooccurring disorders in states and communities
with support from SAMHSA, including
funding from the block grants and a new cooccurring disorder grant program.19
Children’s Health Act of 2000
(P.L. 106-310)
Reauthorized SAMHSA Programs
•
Mental health and substance abuse block grants
•
Comprehensive community mental health services
for children with serious emotional disturbance
•
Projects for Assistance in Transition from
Homelessness (PATH)
•
Protection and Advocacy for Individuals with Mental
Illness (PAIMI)
•
Programs of Regional and National Significance
(PRNS; general authority for CSAT, CSAP & CMHS)
Significant New SAMHSA Programs
•
Child anti-violence initiatives
•
Services for juvenile offenders with serious
emotional disturbances
•
Jail diversion programs for adults
•
Integrated treatment programs for co-occurring
disorders
•
Emergency mental health centers
•
Suicide prevention
•
Mental illness awareness training
•
Methamphetamine and amphetamine treatment
initiative
•
Restraint and seclusion
The second report, delivered in 2005,
discusses SAMHSA’s efforts to improve the
•
Child welfare and mental health service integration
flexibility and accountability of the block
SAMHSA Reports to Congress
grants. The report describes the extent to
•
Services for co-occurring substance abuse and
which states can direct block grant funding to
mental health problems
priority mental health and substance abuse
•
Program performance and accountability
services in order to meet the specific needs in
that state. It also describes the performance
data that SAMHSA collects to measure the
effect of the block grant funding on patient outcomes in each state.20 See the “Performance
Measurement and Accountability” section later in this report for additional information.
17
PHSA Secs. 595, 595A, and 595B.
42 CFR 483 Subpart G (2003).
19
SAMHSA, “Report to Congress on the Prevention and Treatment of Co-occurring Substance Abuse Disorders and
Mental Disorders,” November 2002, at http://www.samhsa.gov/reports/congress2002/index.html.
20
SAMHSA, “A Report Required by Congress on Performance Partnerships: A Discussion of SAMHSA’s Efforts to
Increase Accountability Based on Performance in Its Block Grant Programs by Instituting National Outcome
Measures,” September 2005, at http://www.nationaloutcomemeasures.samhsa.gov/./PDF/performance_partnership.pdf.
18
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The 2000 reauthorization legislation incorporated two additional titles, both of which impact
SAMHSA. First, the Drug Addiction Treatment Act (DATA) of 200021 expanded the options for
treating opioid (heroin) addiction beyond traditional treatment programs (i.e., methadone
maintenance clinics). The act permits qualified physicians to dispense or prescribe specifically
approved opioid treatment medications in their offices. SAMHSA is responsible for approving
physicians to participate in the program.22
Second, the Methamphetamine Anti-Proliferation Act of 200023 established several new programs
to combat methamphetamine abuse, including increased criminal penalties, enhanced law
enforcement, and new research. The act also authorized a new SAMHSA grant program to
expand methamphetamine treatment services in areas with high levels of abuse.24 In addition, it
required the SAMHSA-administered National Survey on Drug Use and Health to collect
information on methamphetamine and other illicit drug use in rural and metropolitan areas.
New Authorizations Since 2000
Congress has enacted a number of laws since the 2000 reauthorization that have further expanded
SAMHSA’s statutory authority. These new authorizations have built on existing programs that
focus on specific issues, such as suicide prevention, underage drinking, and prescription drug
abuse. In addition, the Patient Protection and Affordable Care Act of 2010 (PPACA),25 as
amended by the Health Care and Education Reconciliation Act (HCERA),26 contained new
authorizations for SAMHSA, as well as additional provisions related to mental health and
substance abuse, which are discussed in the next section of this report.
The Garrett Lee Smith Memorial Act of 200427 authorized three significant suicide prevention
programs at SAMHSA—two grant programs and a resource center. These programs support the
planning, implementation, and evaluation of organized activities involving statewide youth
suicide early intervention and prevention strategies; provide grants to institutions of higher
education to reduce student mental and behavioral health problems; support a national suicide
prevention hotline; and fund a national technical assistance center for suicide prevention. For
links to information on Garrett Lee Smith grantee activities, see Appendix C.
In addition, two laws passed since 2000 authorize efforts to reduce and prevent underage
drinking. The No Child Left Behind Act of 200128 required SAMHSA to provide consultation to
the Secretary of Education in awarding grants to local educational agencies for reducing alcohol
abuse in secondary schools. In addition, the 2005 Sober Truth on Preventing Underage Drinking
(STOP) Act29 authorized SAMHSA to award grants for designing, evaluating, and disseminating
21
P.L. 106-310, Title XXXV.
More information on SAMHSA’s administration of the DATA 2000 program is at http://buprenorphine.samhsa.gov/.
23
P.L. 106-310, Title XXXVI.
24
PHSA Sec. 514.
25
P.L. 111-148.
26
P.L. 111-152.
27
P.L. 108-355.
28
P.L. 107-110, Sec. 4129.
29
P.L. 109-422.
22
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community-wide approaches to preventing and reducing underage drinking, and for preventing
underage drinking at institutions of higher education. This act also required SAMHSA to
participate in the Interagency Coordinating Committee on the Prevention of Underage Drinking,
which is intended to guide federal policy and program development related to underage drinking.
SAMHSA has been providing leadership for this committee.
The National All Schedules Prescription Electronic Reporting Act (NASPER) of 2005,30 which
was enacted in response to growing concern about the abuse of prescription drugs regulated under
the Controlled Substances Act,31 authorized a SAMHSA formula grant program for states to
establish or improve an existing prescription drug monitoring program (PDMP). A PDMP is a
statewide electronic database that collects prescriber and patient information on controlled
substances dispensed by pharmacists in order to monitor prescription drug abuse, addiction, and
diversion.32 SAMHSA’s NASPER program is similar to a grant program administered by the U.S.
Department of Justice, the Harold Rogers Prescription Drug Monitoring Program (HRPDMP).33
The HRPDMP provides grants to states for planning, implementation, or enhancement of PDMPs.
The Patient Protection and Affordable Care Act
PPACA (P.L. 111-148) contained several provisions relating to mental health and substance abuse
services, including new SAMHSA authorities. Other provisions not directly related to SAMHSA
still change the landscape of mental health and substance abuse services, which in turn could
impact SAMHSA programs.
PPACA provisions directly related to SAMHSA include three new programs and new grant
requirements for Indian tribes and tribal organizations. PPACA authorizes SAMHSA to establish
national centers of excellence for depression to focus on treatment of depressive disorders,34 and
to establish demonstration projects to provide coordinated and integrated services through the colocation of primary and specialty care services in community-based mental and behavioral health
settings.35 In addition, through reauthorization of the Indian Health Care Improvement Act,
PPACA requires SAMHSA to simplify access to grant funding for Indian tribes, and authorizes
the agency to establish a demonstration program to test the effectiveness of a culturally
compatible, school-based, life skills curriculum for the prevention of Indian and Alaska Native
adolescent suicide.36
30
P.L. 109-60.
P.L. 91-513, Title II.
32
The controlled prescription drugs that are most often abused include painkillers such as codeine and oxycontin;
depressants, including sleeping pills and anti-anxiety drugs; and stimulants such as ritalin, which is used to treat
attention-deficit hyperactivity disorder (ADHD).
33
Additional information on HRDMP and prescription drug monitoring programs can be found on the Department of
Justice’s website at http://www.deadiversion.usdoj.gov/faq/rx_monitor.htm.
34
PHSA Sec. 520B.
35
PHSA Sec. 520K.
36
P.L. 111-148, Sec. 10221.
31
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Other mental health and substance abuse provisions in PPACA focus on expanding the behavioral
health workforce and improving access to behavioral health services. Workforce provisions
include grant programs for recruitment and education of behavioral health providers,37 as well as
a grant program to educate primary care providers about preventive medicine, health promotion,
chronic disease management, evidence-based therapies and techniques, and mental and
behavioral health services in order to encourage primary care providers to incorporate these
elements into their practice.38 These workforce provisions are subject to appropriations.39 PPACA
also requires that the health plans available through state-based exchanges, beginning in 2014,
include mental health and substance abuse services, and that they be offered at parity with
medical/surgical coverage.40
Strategic Direction
SAMHSA has been guided by two long-term planning documents that addressed its strategic
direction through FY2011 with regard to allocation of its discretionary funds and evaluation of its
grant programs. These documents are the SAMHSA Strategic Plan, FY2006-FY2011, and the Data
Strategy Plan, FY2007-FY2011. In October 2010, SAMHSA released a new document – Leading
Change: A Plan for SAMHSA’s Roles and Actions, 2011-2014. This new plan outlines eight
strategic initiatives that the agency will use to guide its work over the next few years. The
strategic initiatives capture many of the priorities in the earlier strategic plan, but also include
newly emerging issues.
SAMHSA Strategic Plan, FY2006-FY2011
SAMHSA’s Strategic Plan contains a Priorities Matrix,41 which lists the mental health and
substance abuse priority areas addressed by the agency, along with the cross-cutting principles
SAMHSA applies to each issue area. Most of the priority areas in this matrix are policy issues
that span the work of its three centers. They include individual health concerns like co-occurring
mental health and substance abuse disorders, suicide, behavioral health issues for individuals with
hepatitis and HIV/AIDS; societal issues like homelessness, and criminal justice; and systemslevel issues like treatment capacity and workforce development. The principles that cut across
these priorities include use of evidence-based practices, evaluation, collaboration, cultural
competence, stigma reduction, and cost-effectiveness.
37
United States Public Health Sciences Track (PHSA Secs. 271-274) and Mental and Behavioral Health Education and
Training Grants (PHSA Secs. 756-757).
38
Primary Care Extension Program (PHSA Sec. 5405).
39
See the following CRS reports for information on appropriations and discretionary funding in PPACA: CRS Report
R41301, Appropriations and Fund Transfers in the Patient Protection and Affordable Care Act (PPACA); and CRS
Report R41390, Discretionary Funding in the Patient Protection and Affordable Care Act (PPACA).
40
See the following CRS reports for information on PPACA, including provisions related to workforce and parity: CRS
Report R41278, Public Health, Workforce, Quality, and Related Provisions in PPACA: Summary and Timeline; and
CRS Report R41249, Mental Health Parity and the Patient Protection and Affordable Care Act of 2010.
41
SAMHSA, Strategic Plan FY2006-FY2011, April 2006, http://www.samhsa.gov/About/SAMHSAStrategicPlan.pdf.
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SAMHSA Data Strategy, FY2007-FY2011
The Data Strategy Plan discusses SAMHSA’s National Outcome Measures (NOMs) (see
Appendix B). The NOMs are a set of performance measures that track mental health and
substance abuse outcomes on the state and program level. SAMHSA introduced the NOMs in
order to monitor progress in mental health and substance abuse and to help determine the impact
of the block grant funding and other grant programs. The NOMs are organized across 10 domains
and apply to the agency’s mental health, substance abuse prevention, and substance abuse
treatment activities. The domains include reduced morbidity, employment/education, crime and
criminal justice, stability in housing, social connectedness, access/capacity, retention, perception
of care, cost effectiveness, and use of evidence-based practices. For additional discussion of data
and performance, see the “Performance Measurement and Accountability” section below.
SAMHSA Strategic Initiatives, 2011-2014
SAMHSA’s eight strategic initiatives (see text box below), which are described in Leading
Change: A Plan for SAMHSA’s Roles and Actions,42 echo many of the priorities and cross- cutting
principles found in the Strategic Plan and Data Strategy, such as prevention, justice,
homelessness, data and outcomes, and public support. However, the initiatives also reflect new
priorities, such as military families, health care reform, and jobs and the economy. SAMHSA
chose these initiatives in order to focus resources on areas where they could have the greatest
impact. For each of the eight initiatives, SAMHSA has identified a lead within the agency
responsible for that initiative. SAMHSA’s FY2011 budget request reflects priorities from the
strategic initiatives with proposals focusing on prevention, homelessness, and data collection.43
SAMHSA’s Strategic Initiatives
1. Prevention of substance abuse and mental illness
5. Housing and homelessness
2. Trauma and justice
6. Health information technology
3. Military families
7. Data, outcomes, and quality
4. Health care reform implementation
8. Public awareness and support
42
SAMHSA, Leading Change: A Plan for SAMHSA’s Roles and Actions, 2011-2014, October 2010, Draft,
http://www.samhsa.gov/about/sidocs/SAMHSA_SI_paper.pdf.
43
SAMSHA FY2011 Budget Justification at http://www.samhsa.gov/Budget/FY2011/SAMHSA_FY11CJ.pdf.
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Current Reauthorization Issues
It has been a decade since Congress passed comprehensive SAMHSA reauthorization legislation.
As shown in Table A-1 in Appendix A, most of the authorizations of appropriations for
SAMHSA’s programs expired at the end of FY2003. Legislation to reauthorize SAMHSA was
introduced in the 111th Congress, but has not moved out of committee.44 This last section of the
report briefly describes several issues that could be considered during congressional debate on
SAMHSA reauthorization.
Reauthorization Issues
Issues that may be of interest during reauthorization of
•
Performance measurement
SAMHSA include increased performance measurement and
and accountability
accountability for SAMHSA grants and programs, granting
specific authority for the Access To Recovery program that
•
Access to Recovery
provides vouchers for individuals to seek treatment services and
•
Disaster response
that was created under SAMHSA’s general authority, improving
•
Collaboration with other
the ability of communities to provide behavioral health services
federal agencies
during disaster response, requiring collaboration between
•
Focus on prevention and
SAMHSA and other federal agencies, increasing SAMHSA’s
early
intervention
level of emphasis on primary prevention, increasing SAMHSA’s
role in expanding the number and diversity of the behavioral
•
Workforce issues
health provider workforce, and ensuring fairness of the formula
•
Block grant formula
used to distribute SAMHSA’s block grants.45
Performance Measurement and Accountability
The National Outcome Measures (NOMs) were developed by SAMHSA in order to create a
standard set of measures and definitions by which to track the progress of states and programs in
improving mental health and reducing substance abuse. The NOMs are organized across 10
domains and apply to the agency’s mental health, substance abuse prevention, and substance
abuse treatment activities. For instance, substance abuse prevention NOMs under the reduced
mortality domain measure alcohol use in the past 30 days, perceived risk of harm from alcohol
use, disapproval of peer alcohol use, and age of first alcohol use. See Appendix B for the
complete matrix of NOMs, by domain.
44
The SAMHSA Modernization Act of 2010 (H.R. 5466), introduced by Representatives Patrick Kennedy (D-RI) and
Gene Green (D-TX), includes comprehensive reauthorization of SAMHSA programs, extending most authorizations of
appropriations through FY2015. In addition to reauthorizing existing programs, the bill includes new grant programs to
integrate mental health and substance use disorder services into primary care settings, address the mental health needs
of older adults, and recruit and retain qualified mental health and substance use professionals. The bill also requires the
Secretary to study whether block grant funding is distributed accurately based on need and to recommend changes in
such distribution, if necessary.
45
CRS selected issues that may be of interest during reauthorization based on a variety of factors, including issues
raised in the SAMHSA Modernization Act of 2010 (e.g., performance measurement and accountability and the
behavioral health workforce), gaps in behavioral health response exposed during recent disasters (e.g., disaster
response), and recent research and reports related to the federal role in behavioral health (prevention and early
intervention). The issues discussed in this report are not an exhaustive list of items that may be addressed during a
comprehensive reauthorization of SAMHSA programs.
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In FY2008, SAMHSA began requiring states to report state-level NOMs data as a condition of
receiving block grant funding. SAMHSA also uses the NOMs, as well as other performance
measures, to track and manage each of its programs. Currently, SAMHSA, as well as the states
themselves, use the NOMs to monitor progress on improving mental health and substance abuse
services, and to identify areas in need of additional attention.
SAMHSA currently does not tie state funding to the mental health and substance abuse outcomes
reported in the NOMs data. Holding states accountable for the mental health and substance abuse
services by linking NOMs performance to funding could improve program performance and state
outcomes. Options for applying an accountability system include establishing national goals for
some or all of the NOMs and setting state-specific goals for the NOMs. However, given the
variability in data collection among the states, as well as variability in the types and severity of
substance abuse problems within each state, requiring states to meet a national goal may not be
realistic. Each state could instead be required to show improvement on performance measures
over time. That would allow SAMHSA to take into account the baseline performance and the
different mental health and substance abuse landscape in each state.
Access to Recovery
The Access to Recovery (ATR)46 program is an initiative proposed by former President George
W. Bush in FY2003 that awards grants to states and tribes for providing vouchers to clients for
the purchase of substance abuse clinical treatment services and recovery support services.
Recovery support services are those services that support individuals as they obtain treatment for
substance abuse. They include care coordination, child care, transportation, and work preparation.
The ATR program is not directly authorized in statute, instead it is carried out under CSAT’s
general PRNS authority. Funding for the program has remained flat at just under $100 million
each year since it began in FY2004. However, SAMHSA has requested an increase of almost $10
million for FY2011 to fund up to four new ATR grants.47
In FY2004, SAMHSA awarded three-year ATR grants to an initial cohort of 15 grantees. Another
round of three-year grants were awarded to 24 grantees in FY2007. SAMHSA recently
announced that it was awarding 30 new ATR grants, each one for up to four years. The annual
amount of each grant ranges from $2 million to $4 million.48 In FY2007, SAMHSA began an
assessment to determine the effectiveness of the ATR program. SAMHSA anticipates releasing
the results of the assessment in late 2010.
A centerpiece of the ATR program is the use of vouchers to fund substance abuse treatment and
support services, which is different from other SAMHSA programs that provide states or other
entities with direct grant funding for services and programs. Under the ATR program, states use
program funds to evaluate patients and provide vouchers for the patient to obtain treatment
services from an approved provider of his or her choice. Because ATR’s vouchers represent an
indirect source of federal funding for service providers, faith-based providers may participate in
the program without restrictions on the incorporation of religious activities. For more information
46
ATR program details are available at http://atr.samhsa.gov.
SAMHSA FY2011 Budget Justification at http://www.samhsa.gov/Budget/FY2011/SAMHSA_FY11CJ.pdf.
48
Substance Abuse and Mental Health Services Administration, “SAMHSA awards $379 million for Access to
Recovery grants,” press release, October 8, 2010, http://www.samhsa.gov/newsroom/advisories/1010081330.aspx.
47
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on the conditions under which faith-based providers may receive SAMHSA funding, see the text
box on the agency’s charitable choice provisions.
Charitable Choice
The 106th Congress enacted two laws with charitable choice provisions that apply to substance abuse prevention
and treatment services funded by SAMHSA.49 The intent of these provisions is to permit faith-based organizations
to compete on equal terms for SAMHSA substance abuse funding without impairing the religious character of
such organization and without diminishing the religious freedom of program beneficiaries.
Under SAMHSA’s charitable choice provisions, direct federal funds may not be used for inherently religious
activities, such as worship or religious instruction. However, a religious organization may retain its religious
character and continue to carry out its religious mission provided such activities are conducted separately, in time
and location, from the substance abuse services for which it receives direct funding. Moreover, religious
organizations that receive SAMHSA funding may continue to consider job applicants’ religious beliefs in hiring
decisions. Such organizations may not discriminate against individuals seeking substance abuse services on the
basis of religion, and must provide individuals who object to the organization’s religious character with an
alternative service provider.
If federal funds are provided indirectly, the courts have ruled that religious activities do not have to be excluded
from the social services supported by those funds because it is the beneficiary and not the government that
selects the faith-based provider. Thus, the government is not responsible for any religious activities that might
accompany the social services that the funds support. ATR vouchers are an indirect source of funds, therefore,
faith-based organizations that provide substance abuse prevention and treatment services under the ATR program
may incorporate religion into those services.
Disaster Response
SAMHSA played a significant role in providing mental health and substance abuse services after
hurricanes Katrina and Rita hit the Gulf Coast states in 2005. During 2010, the Haiti earthquake
and the Deepwater Horizon oil spill in the Gulf of Mexico again highlighted the mental health
impact of disasters and the resulting need for services. In the wake of these recent incidents, some
experts believe that effective disaster assistance must build upon the existing behavioral health
resources in affected communities.50 However, many communities may not have the necessary
infrastructure to support the surge in need after a disaster.
SAMHSA currently has authority to provide emergency behavioral health assistance through
three mechanisms: the Crisis Counseling Assistance and Training Program (CCP), SAMHSA
Emergency Response Grants (SERG), and supplemental appropriations. The CCP provides shortterm federal assistance to state and local governments to address mental health needs when there
is a presidentially declared disaster.51 States apply for funds by preparing a formula-based needs
assessment within 10 days of the date of the disaster declaration. There is no matching
requirement, and requested CCP funds must supplement, not supplant, existing local or state
49
SAMHSA’s charitable choice provisions are located in PHSA Secs. 581-584 and Sec. 1955, which were added by
the Children’s Health Act of 2000 (P.L. 106-310) and the Consolidated Appropriations Act (P.L. 106-554),
respectively. The provisions added by the two laws are broadly similar and apply to the competitive and formula grant
programs under PHSA Title V and the two block grants under Title XIX. Implementing regulations are at 45 CFR Parts
54 and 54a.
50
Katherine Yun, Nicole Lurie, and Pamela S. Hyde, “Moving Mental Health into the Disaster-Preparedness
Spotlight,” New England Journal of Medicine, August 11, 2010.
51
The Robert T. Stafford Disaster Relief and Emergency Assistance Act (the Stafford Act) provides authority, when
there is a presidentially declared disaster, for federal assistance to state and local governments to address the mental
health needs of victims (42 USC § 5183).
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resources. While CCP provides funds for up to nine months after a disaster, the regulations permit
extensions in certain cases.52
SAMHSA may also redirect some of its funding through the SERG authority to make noncompetitive grants to address emergency substance abuse or mental health needs in communities
without a presidentially declared disaster. In order to receive funding, a state must certify that a
mental health or substance abuse emergency exists, and the emergency must be the direct
consequence of a clear precipitating event, such as a natural disaster. Like CCP funding, states
may receive SERG grants only if no other resources are available to adequately address the need.
Apart from CCP and SERG, if Congress provides SAMHSA with supplemental funds for disaster
response, these funds could be used under SAMHSA’s existing authorities to support behavioral
health treatment services.
In addition to the disaster-specific authorities described above, SAMHSA has multiple programs
that focus on building local mental health and substance abuse infrastructure and capacity. For
instance, the Mental Health System Transformation Grant supports transformative changes in
how communities manage and deliver mental health services, and the Targeted Capacity
Expansion program provides funding for communities to build capacity to address gaps in
substance abuse treatment services. These programs do not have specific authorizations, but
are instead administered under SAMHSA’s general authorities (i.e., PRNS). By improving the
availability and delivery of behavioral health services in states and communities, these programs
also build a stronger base for providing services after a disaster.53
Collaboration with Other Federal Agencies
Numerous federal agencies play a role in the provision of mental health and substance abuse
services. While SAMHSA focuses on community-based prevention and treatment services for
individuals with mental health and substance abuse conditions, other federal agencies, such as the
Department of Education (ED) and the Indian Health Service (IHS), also support and/or provide
these services to specific populations or provide related services, such as housing and education.
There are few statutory requirements by which these federal agencies are required to work with
SAMHSA.54 However, some experts believe that due to the wide range of socioeconomic risk
factors for mental health and substance abuse disorders, as well as the negative socioeconomic
effects of these disorders, there needs to be more collaboration between SAMHSA and other
federal agencies.55
Collaboration between SAMHSA and other federal agencies has been used to prevent duplication
of efforts and provide a platform for sharing expertise. For example, SAMHSA and the
52
44 C.F.R. § 206.171.
Information on SAMHSA’s disaster response programs can be found at http://www.samhsa.gov/disaster.
54
PHSA Sec. 501 authorizes SAMHSA to collaborate with the National Institutes of Health to disseminate the research
findings of NIDA, NIAAA, and NIMH to service providers in order to improve the delivery of services and to promote
the coordination of programs conducted by other federal agencies, including the Social Security Administration,
Centers for Medicare and Medicaid Services, Department of Education, and Department of Justice, as appropriate,
related to the problems of individuals suffering from mental illness or substance abuse. PHSA Sec. 581 requires
SAMHSA to work in consultation with ED to administer a program to prevent violence in schools (see Table A-1).
55
National Association of School Psychologists, Position Statement on Interagency Collaboration to Support the
Mental Health Needs of Children and Families, July 2006.
53
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Department of Veterans Affairs (VA) work together to provide a 24-hour suicide prevention
hotline for veterans.56 The VA built upon the existing national suicide hotline administered by
SAMHSA in order to create veteran-specific suicide prevention services. The veteran suicide
hotline utilizes the national hotline number and training resources, but routes veterans to
counselors with additional training in working with veterans. In addition, SAMHSA works with
the ED to administer the Safe Schools/Healthy Students program,57 which provides grants to
schools for violence and substance abuse prevention activities.
Additional collaboration with federal agencies, including those described below, may improve
SAMHSA’s ability to reach at-risk populations and provide support services to those with mental
health and substance abuse conditions. The Department of Justice and ED serve youth with
substance abuse and mental health problems who are also the focus of many SAMHSA programs.
The Centers for Disease Control and Prevention’s (CDC) Injury Prevention and Control Program
works on prevention and surveillance in the fields of violence, suicide, and mental health. IHS
also serves a population that has significant substance abuse problems, along with issues of
access to mental health care. VA provides health care to veterans many of whom suffer from
mental illness and substance abuse. In addition, the U.S. Department of Housing and Urban
Development provides housing services, a support service also provided through some SAMHSA
programs for individuals with mental health and substance abuse conditions, including homeless
individuals (see Table A-1).
Focus on Prevention and Early Intervention
The 1999 Surgeon General’s Report on Mental Health58 and the 2003 President’s New Freedom
Commission Report59 framed mental health as a public health issue. The reports advised applying
a public health approach that would emphasize prevention and early intervention, rather than
focusing on individuals who have become severely ill and expensive to treat. The reports also
recommended a wholesale transformation of the nation’s approach to mental health care
involving consumers and providers, policymakers at all levels of government, and both the public
and private sectors.
These recommendations are echoed in a 2009 report by the Institute of Medicine (IOM) on
preventing mental, emotional, and behavioral health problems among young people. Several
years after the Surgeon General’s Report and the President’s New Freedom Commission, the IOM
report stated: “No concerted federal presence or clear national leadership currently exists to
advance the use of prevention and promotion approaches to benefit the mental health of the
nation’s young people.”60
56
The Joshua Omvig Veterans Suicide Prevention Act (P.L. 110-110) authorized VA to establish a suicide prevention
hotline for veterans; however, it did not require collaboration with SAMHSA. Additional information on the veteran
suicide prevention hotline can be found at http://www.suicidepreventionlifeline.org/Veterans/Default.aspx.
57
See the Safe Schools/Healthy Students website for more information at http://www.sshs.samhsa.gov/default.aspx.
58
The 1999 Surgeon General’s Report on Mental Health can be accessed online at http://www.surgeongeneral.gov/
library/mentalhealth/home.html.
59
The 2003 President’s New Freedom Commission Report can be accessed online at
http://www.mentalhealthcommission.gov/reports/FinalReport/toc.html.
60
Mary Ellen O’Connel, Thomas Boat, and Kenneth E. Warner, Preventing Mental, Emotional, and Behavioral
Disorders Among Young People: Progress and Possibilities, National Research Council and Institute of Medicine,
Washington, DC, 2009, http://books.nap.edu/openbook.php?record_id=12480&page=R1.
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In response to these and other reports, SAMHSA has implemented a number of new prevention
initiatives for mental health and substance abuse. For instance, the agency has funded states to
develop plans that would transform the individual-focused behavioral health care system into a
more public health oriented system. SAMHSA also created the Strategic Prevention Framework
(SPF) in 2004, which includes a five-step process for preventing substance abuse in
communities.61 This framework has been applied through the SPF State Incentive Grants, the
prevention set-aside in the SAPT block grant, and the HIV prevention program in CSAP. In 2008,
SAMHSA launched the Linking Actions for Unmet Needs in Children’s Health (LAUNCH)
Initiative, which provides grants to states and tribal organizations to promote and enhance the
wellness of young children by increasing capacity to develop infrastructure and implement
prevention/promotion strategies necessary to promote wellness for young children aged zero to
eight. This program currently focuses on mental health; however, SAMHSA has proposed
expanding the focus to include substance abuse prevention in FY2011.
SAMHSA also supports some early intervention efforts. In order to identify and treat mental
illness and substance abuse early, SAMHSA encourages states to reduce system fragmentation
and increase services available to people living with mental illness. SAMHSA also funds
treatment programs that function as a safety net for at-risk populations such as pregnant and
postpartum women, vulnerable youth, and homeless individuals.
Notwithstanding recent efforts to increase prevention and early intervention activities,
SAMHSA’s budget still reflects a greater emphasis on substance abuse treatment over prevention,
with more overall funding and larger increases over the past ten years for treatment services. As
shown in Figure 2, funding for substance abuse prevention PRNS has grown 37% in the past
decade, a relatively flat funding trend after accounting for inflation, while funding for substance
abuse treatment PRNS has more than doubled. In FY2010, funding for substance abuse treatment
PRNS was more than twice the level of funding for substance abuse prevention PRNS (see Table
A-2). SAMHSA’s budget does not similarly break out treatment and prevention for mental health.
Workforce Issues
A 2006 IOM report62 identified the inadequacy of the training and number of mental health and
substance abuse treatment providers and recommended building, maintaining, and ensuring a
competent and qualified behavioral health workforce. While SAMHSA has the authority to
collect and analyze workforce data as well as support training programs for providers,
historically, the agency has provided limited support for workforce training through the relatively
small Minority Fellowship Program (MFP), which provides fellowships for minority mental
health care providers. This program falls under SAMHSA’s general authority (i.e., PRNS), and its
funding level is subject to annual congressional appropriations.
61
The five steps in the Strategic Prevention Framework are 1) conduct a community needs assessment, 2) mobilize
and/or build capacity, 3) develop a comprehensive strategic plan, 4) implement evidence-based prevention programs
and infrastructure development activities, and 5) monitor process and evaluate effectiveness. Additional information
about the Strategic Prevention Framework can be found at http://prevention.samhsa.gov/about/spf.aspx.
62
Institute of Medicine, Improving the Quality of Health Care for Mental and Substance-Use Conditions: Quality
Chasm Series, Washington, DC, 2006, http://books.nap.edu/openbook.php?record_id=11470.
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SAMHSA: Agency Overview and Reauthorization Issues
As discussed above, PPACA contained several provisions aimed at increasing and improving the
health workforce, including the behavioral health workforce.63 While not located within
SAMHSA, these newly authorized programs could mitigate some of the issues identified in the
2005 IOM report regarding the shortage of mental health and substance abuse providers.
However, these programs are also subject to the annual appropriations process.64
Block Grant Formula
SAMHSA’s mental health and substance abuse prevention and treatment block grants are
distributed using a formula that is in statute. As detailed later in this section, concerns have been
raised by economists and health policy experts about the appropriateness of this formula to ensure
that the distribution of block grant funding to the states matches the need in each state.
History of SAMHSA Block Grants
The Alcohol, Drug, and Mental Health Services (ADMHS) block grant was one of seven block
grants established by the Omnibus Budget Reconciliation Act of 1981 (OBRA).65 This block
grant consolidated several existing categorical grant programs for substance abuse and
community mental health services in order to provide state and local governments with more
flexibility and control over funding, to enhance their ability to meet localized needs, to end
duplication of effort in delivering services, and to enable more coordination. OBRA authorized
ADMHS block grant funds for FY1982 through FY1984 in proportion to the historical funding
patterns of the original categorical grants. To better match block grant funding with the need in
each state, OBRA also directed HHS to conduct a study that would produce a funding allocation
formula, considering population and state fiscal capacity.
The 1984 ADAMHA Amendments66 included an allocation formula and reauthorized funding for
the block grants for three years with a “minor equity adjustment” to hold harmless states that
would have otherwise received decreased funding under the new calculation. Funds above the
hold-harmless level (i.e., the amount states received in FY1984) were to be allocated using a
formula based equally on state population and relative per capita income. The law also required a
non-governmental entity to provide recommendations on the formula proposed by HHS. The
resulting recommendations, from the Institute for Health and Aging (IHA),67 included phasing out
the hold-harmless provisions, allocating funds based on populations at risk, and incorporating a
state fiscal capacity measure.
The 1988 Anti-Drug Abuse Act68 revised the block grant formula, based on the IHA
recommendations, to phase out the hold-harmless provision, use total taxable resources as the
63
United States Public Health Sciences Track (PHSA Sections 271-274), Mental and Behavioral Health Education and
Training Grants (PHSA Sections 756-757), Primary Care Extension Program (PHSA Sec. 5405).
64
See the following CRS reports for information on appropriations and discretionary funding in PPACA: CRS Report
R41301, Appropriations and Fund Transfers in the Patient Protection and Affordable Care Act (PPACA); and CRS
Report R41390, Discretionary Funding in the Patient Protection and Affordable Care Act (PPACA).
65
P.L. 97-35.
66
P.L. 98-509.
67
IHA is an institute within the University of California, San Francisco.
68
P.L. 100-690.
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SAMHSA: Agency Overview and Reauthorization Issues
measure of state fiscal capacity, and incorporate weighted age cohorts as a measure of population
at risk. The high-risk age cohorts, determined using an IHA study, were 25-64 years for alcohol
abuse, 18-24 years for other drug abuse, and 25-44 for selected mental disorders. Later studies
indicated that the inequalities in matching block grant funding to need persisted even after the
IHA recommendations were implemented.69
The 1992 ADAMHA Reorganization Act70 split the ADMHS block grant into two separate block
grants, one for community mental health services (CMHS block grant) and another for substance
abuse prevention and treatment services (SAPT block grant). The population-at-risk component
of the formula was further adjusted to reflect the differences in the population in need of mental
health and substance abuse services.71
The 2000 Children’s Health Act again revised the block grant formulas by reintroducing holdharmless provisions for both block grants.72 For the SAPT block grant, the new provisions specify
that a state must receive no less than the previous year’s allocation plus a defined portion of any
funding increase for the program. If there is a decrease in appropriations for the SAPT block
grant, each state gets a proportionate decrease in their block grant allocation. For the CMHS
block grant, the new provisions provide only that a state must not receive less than the FY1998
allotment.
Figure 3. Block Grant Timeline
Block grants renewed for 3
years by ADAMHA
Amendments. Formula based
on state population and relative
per capita income, with a holdharmless provision.
1981
Block grants created
by OBRA, replacing
several categorical
grants. Formula
based on
distribution of
replaced grants.
1984
ADAMHA Reorganization Act
split block grant into two.
Formula revised for differences
in the population in need of
mental health and substance
abuse services.
1988
Formula revised by the Anti-Drug
Abuse Act to phase out the holdharmless provision, use total
taxable resources for state fiscal
capacity, and incorporate
weighted age cohorts for the
population at risk.
1992
2000
The Children’s Health Act
added a state minimum and a
hold-harmless provision (no
less than the FY1998 amount
for CMHS block grant and no
less than the previous year’s
amount for SAPT block grant).
69
General Accounting Office (now Government Accountability Office), T-HRD-91-38, Substance Abuse Funding: Not
Justified by Urban-Rural Differences in Need, 1991.
70
P.L. 102-321.
71
General Accounting Office (now Government Accountability Office), T-HRD-91-32, Mental Health Grants:
Funding Not Distributed in Accordance with State Needs, 1991.
72
P.L. 106-310, Title XXXII, Sec. 3205 (CMHS block grant) and Title XXXIII, Sec. 3304 (SAPT block grant).
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SAMHSA: Agency Overview and Reauthorization Issues
Current Formula
The formula for calculating a state’s SAPT and CMHS block grant allocations73 takes into
account three measures: (1) the population-at-risk in the state; (2) the costs of services in the
state; and (3) the fiscal capacity of the state.
The first factor, population-at-risk, is intended to be a proxy for the extent of need for services in
a state. For the SAPT block grant, this factor is an average of two ratios equally weighted. The
first ratio is the number of individuals age 18-24 plus the number of individuals of the same age
group who reside in urban areas in a state, divided by the sum of the same populations for all the
states. The second ratio is the number of individuals ages 25-64 in a state divided by the sum of
the same populations of all the states. For the CMHS block grant, this factor is calculated based
on the state population of individuals ages 18-24, 25-44, 45-64, and over 65, with a different
weight applied to each age group. The second factor, cost of services, is derived from the 1990
report of Health and Economics Research, Inc., and ranges from 0.9 to 1.1.74 The third factor,
which is the fiscal capacity of the state, is intended to adjust for differences in state capacity to
pay for these services. This factor uses the three-year mean of the total taxable revenue of the
state.
The three factors mentioned above are multiplied to produce a score for the state. To calculate the
grant amount for a given state, the state’s score is divided by the sum of all the states’ (and
District of Columbia’s) scores and that value is then multiplied by the total amount appropriated
for the grant program.75 The formula can be written as:
51
Gi = A ( Xi / ΣXi)
i=1
{i(state) = 1, 2, ..., 51}
where
Gi = grant amount for the ith state
A = total funds appropriated for distribution among the states
Xi = score for the ith state
Issues Regarding Current Formula
A number of issues have been raised regarding the current formula. First, the formula does not
consider variations in numbers of uninsured individuals across the states, nor does it take into
73
PHSA Secs. 1918 and 1933.
G.C. Pope, “Adjusting the Alcohol, Drug Abuse, and Mental Health Services Block Grant Allocations for Poverty
Population and Cost-of-Service,” Health Economics Research, Inc., Needham, MA, March 30, 1990.
75
Pradip K. Muhuri and Jerome L. Ducrest, Block Grants and Formula Grants: A Guide for Allotment Calculations,
U.S. Department of Health and Human Services, Substance Abuse Mental Health Services Administration, Office of
Applied Studies, August 2007, http://www.oas.samhsa.gov/BG_documentation_070809_final_psg.pdf.
74
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SAMHSA: Agency Overview and Reauthorization Issues
account other federal funding (e.g., Medicare and Medicaid) that a state may also receive for
mental health and substance abuse services. Second, experts recommend using data from national
surveys that measure the level of mental illness and substance abuse in a state (rather than
population age distribution) to determine the population in need of services.76 These surveys
include the National Comorbidity Survey-Replication77 for mental health needs, and NSDUH78
for substance abuse needs, both of which are administered by SAMHSA. Third, research
indicates that the currently used cost-of-services measure does not adequately represent interstate
wage variations in occupations related to substance abuse and mental health.79
76
Burnam et al., Review and Evaluation of Substance Abuse and Mental Health Services Block Grant Allotment
Formula, RAND Corporation, 1997.
77
SAMHSA, The National Comorbidity Survey (NCS-1) studied the prevalence and correlates of mental disorders
from 1990 to 1992. The NCS Replication (NCS-R) was carried out with a new national sample from 2001 to 2003 to
study trends in a wide range of variables assessed in the baseline NCS-1.
78
SAMHSA, NSDUH, which was formerly known as the National Household Survey on Drug Abuse (NHSDA), is
designed to produce drug and alcohol use incidence and prevalence estimates and report the consequences and patterns
of use and abuse in the general U.S. civilian population aged 12 and older.
79
Burnam et al., Review and Evaluation of Substance Abuse and Mental Health Services Block Grant Allotment
Formula, RAND Corporation, 1997.
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Appendix A. SAMHSA Authorizations and Funding
Table A-1 below summarizes the statutory authorizations for each of SAMHSA’s programs. The
table is organized by the three operating centers within SAMHSA—the Center for Substance
Abuse Treatment (CSAT), the Center for Substance Abuse Prevention (CSAP), and the Center for
Mental Health Services (CMHS)—which mimics the organization of the authorizations under
PHSA Title V. Authorizations not within Title V (e.g., block grants) are listed at the end of each
section and at the end of the table.
Each table entry includes the PHSA section number (or relevant public law and section number
for the few authorizations not in the PHSA), the title and a brief description of the program’s
authorization, and the year it was created. Here is a list of the authorizing legislation for the
programs summarized in the table, organized by year:
•
1986: Protection and Advocacy for Individuals with Mental Illness Act, P.L. 99-319
•
1988: Anti-Drug Abuse Act, P.L. 100-690
•
1990: Stewart B. McKinney Homeless Assistance Amendments Act, P.L. 101-645
•
1992: Alcohol, Drug Abuse, and Mental Health Administration (ADAMHA)
Reorganization Act, P.L. 102-321
•
2000: Children’s Health Act, P.L. 106-310
•
2004: Garrett Lee Smith Memorial Act, P.L. 108-355
•
2005: National All Schedules Prescription Electronic Reporting Act, P.L. 109-60
•
2005: Sober Truth on Preventing Underage Drinking (STOP) Act, P.L. 109-422
•
2010: Patient Protection and Affordable Care Act, P.L. 111-148
The final three columns show the authorization of appropriations for each program, the FY2010
funding level, and a list of the fiscal years for which funding has been appropriated since
FY2000, which is when many of the programs were created. Typically, an authorization of
appropriations specifies the funding level for the first fiscal year, and authorizes the appropriation
of “such sums as may be necessary” (SSN) in subsequent fiscal years. Almost all of the
authorizations of appropriations expired in FY2003; however, funding continues to be
appropriated for these programs. If funding was not appropriated for FY2010, the table notes this
with an “NF” for not funded. It is also noted if the program has not received any funding since
FY2000. In several instances, programs created in FY2000 have never received funding.
Table A-2 below shows SAMHSA funding, by program area, for the period FY2000 through the
FY2011 budget request. The funding amounts shown in the table include direct appropriations to
SAMHSA plus additional funds transferred to the agency by the HHS Secretary under the PHS
Program Evaluation Set-Aside, authorized by PHSA Sec. 241.
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SAMHSA: Agency Overview and Reauthorization Issues
Table A-1. SAMHSA Program Descriptions, Authorizations of Appropriations, and Funding
PHSA
Section
Year
Created
Title and Program Description
Authorization of
Appropriations
Actual FY2010
Funding
Years Funded
Since 2000
Center for Substance Abuse Treatment (CSAT)
Sec. 399O
National All Schedules Prescription Electronic Reporting (NASPER).
Formula grants to states to establish or improve prescription drug monitoring
programs that collect data on potentially addictive controlled substances dispensed by
pharmacists. Grants also support the development of a set of best practices for these
monitoring programs.
2005
FY2005-FY2006:
$15,000,000 each year
FY2008-FY2010:
$10,000,000 each year
$2,000,000
2009-2010
Sec. 506
Grants for the Benefit of Homeless Individuals. Funds the development of
comprehensive drug/alcohol and mental health treatment systems for the homeless.
1992
FY2001: $50,000,000
FY2002-FY2003: SSN
$42,750,000
2002-2010
Sec. 509
Priority Substance Abuse Treatment Needs of Regional and National
Significance (PRNS). General authority to provide grants and fund activities
intended to increase knowledge on best practices, provide training and technical
assistance, and increase capacity of states and local entities to provide for necessary
substance abuse treatment services.
1992
FY2001: $300,000,000
FY2002-FY2003: SSN
$452,629,000
2002-2010
Sec. 508
Residential Treatment Programs for Pregnant and Postpartum Women.
Grants to expand the availability of comprehensive, high quality residential treatment
services for pregnant and postpartum women who suffer from alcohol and other drug
use problems, and for their minor children impacted by perinatal and environmental
effects of maternal substance use and abuse.
1992
FY2001-FY2003: SSN
$16,000,000
2004-2010
Sec. 514a
Substance Abuse Treatment Services for Children and Adolescents. Grants,
contracts, or cooperative agreement for providing substance abuse treatment
services, early intervention, programs to prevent the use of methamphetamine and
inhalants, and for creating centers of excellence to assist states and local jurisdictions
in providing appropriate care for adolescents who are involved with the juvenile
justice system and have a serious emotional disturbance.
2000
FY2001: $40,000,000
FY2002-FY2003: SSN
$30,678,000
2002-2010
Sec. 514A
Early Intervention Services For Children and Adolescents. Grants to provide
early intervention substance abuse services for children and adolescents.
2000
FY2001: $20,000,000
FY2002-FY2003: SSN
NF
None
Sec. 514a
Methamphetamine and Amphetamine Treatment Initiative. Grants to
expand methamphetamine treatment services in areas with high prevalence of abuse.
2000
FY2000: $10,000,000
FY2001-FY2002: SSN
NF
None
Secs. 19211935
Substance Abuse Prevention and Treatment Performance Partnership
Block Grant. Provides funding to States by formula to plan, carry out, and evaluate
activities to prevent and treat substance abuse.
1992
FY2001: $2,000,000,000
FY2002-FY2003: SSN
$1,719,391,000
2000-2010
CRS-26
SAMHSA: Agency Overview and Reauthorization Issues
PHSA
Section
Year
Created
Title and Program Description
Authorization of
Appropriations
Actual FY2010
Funding
Years Funded
Since 2000
Center for Substance Abuse Prevention (CSAP)
Sec. 516
Priority Substance Abuse Prevention Needs of Regional and National
Significance (PRNS). General authority to provide grants and fund activities
intended to increase knowledge on best practices, provide training and technical
assistance, and increase capacity of states and local entities to provide for necessary
substance abuse prevention efforts.
1986
FY2001: $300,000,000
FY2002-FY2003: SSN
$185,388,000
2002-2010
Sec. 519
Services for Children of Substance Abusers. Grants to provide evaluations,
treatment and referrals to children of substance abusers.
1992
FY2001: $50,000,000
FY2002-FY2003: SSN
NF
None
Sec. 519A
Grants for Strengthening Families. Grants to provide early intervention and
substance abuse prevention services for individuals of high-risk families and their
communities.
2000
FY2001: $3,000,000
FY2002-FY2003: SSN
NF
None
Sec. 519B
Programs to Reduce Underage Drinking. Funding to establish the Interagency
Committee on the Prevention of Underage Drinking, conduct research on underage
drinking, and support a national media campaign to prevent underage drinking. Grants
to design, test, evaluate and disseminate effective strategies to maximize the
effectiveness of community-wide approaches to preventing and reducing underage
drinking. Grants to institutions of higher education to prevent and reduce the rate of
underage alcohol consumption including binge drinking.
2005
FY2007-FY2010:
$18,000,000 each year
$7,000,000
2008-2010
Sec. 519C
Services for Individuals with Fetal Alcohol Syndrome. Grants to provide
services to individuals diagnosed with fetal alcohol syndrome or alcohol-related birth
defects.
2000
FY2001: $25,000,000
FY2002-FY2003: SSN
NF
None
Sec. 519D
Center of Excellence on Services for Individuals with Fetal Alcohol
Syndrome and Alcohol-Related Birth Defects and Treatment for
Individuals with Such Conditions and their Families. Grants to establish
centers of excellence to study prevention and treatment strategies for fetal alcohol
syndrome and alcohol-related birth defects.
2000
FY2001: $5,000,000
FY2002-FY2003: SSN
$9,821,000
2002-2010
Sec. 519E
Prevention of Methamphetamine Abuse and Addiction. Grants to support
expansion of methamphetamine prevention interventions and/or infrastructure
development. This program helps localities to expand prevention interventions that
are effective and evidence-based and/or increase capacity through infrastructure
development. The goal is to intervene effectively to prevent, reduce or delay the use
and/or spread of methamphetamine abuse.
2000
FY2001: $10,000,000
FY2002-FY2003: SSN
NF
2002-2009
CRS-27
SAMHSA: Agency Overview and Reauthorization Issues
PHSA
Section
Year
Created
Title and Program Description
Authorization of
Appropriations
Actual FY2010
Funding
Years Funded
Since 2000
Center for Mental Health Services (CMHS)
Sec. 520A
Priority Mental Health Needs of Regional and National Significance
(PRNS). General authority to provide grants and fund activities intended to increase
knowledge on best practices, provide training and technical assistance, and increase
capacity of states and local entities to provide for necessary substance abuse
prevention efforts.
1988
FY2001: $300,000,000
FY2002-FY2003: SSN
$179,865,000
2002-2010
Sec. 520B
National Centers Of Excellence For Depression. Grants to national centers of
excellence for depression to engage in activities related to the treatment of depressive
disorders, including identifying and supporting implementation of evidence-based
practices, providing training and technical assistance to mental health professionals,
and conducting educational activities to reduce stigma and raise awareness of
treatments.
2010
FY2010-FY2015:
$100,000,000 each year
NF
None
Sec. 520C
Youth Interagency Research, Training, And Technical Assistance Centers.
Grants to establish up to four research, training, and technical assistance centers to
support mental health and substance abuse services within the justice system, and to
establish one center to support youth suicide early intervention and prevention.
2000
FY2001: $4,000,000
FY2002-FY2003: SSN
FY2005: $3,000,000
FY2006: $4,000,000
FY2007: $5,000,000
$4,957,000
2005-2010
Sec. 520D
Services for Youth Offenders. Grants to provide aftercare services to youth
offenders who have been discharged from the justice system and have serious
emotional disturbances.
2000
FY2001: $40,000,000
FY2002-FY2003: SSN
NF
None
Sec.520E
Youth Suicide Early Intervention and Prevention Strategies. Grants to states
and tribal organizations to develop and implement statewide or tribal youth suicide
prevention and early intervention strategies. Efforts must involve public/private
collaboration among youth-serving institutions and agencies and should include
schools, educational institutions, juvenile justice systems, foster care systems,
substance abuse and mental health programs, and other child and youth supporting
organizations.
2004
FY2005: $7,000,000
FY2006: $18,000,000
FY2007: $30,000,000
$29,738,000
2005-2010
Sec.520E-1
Suicide Prevention For Children and Adolescents. Grants to complement
suicide prevention and early intervention strategies developed in Sec. 520E.
2000
FY2001: $75,000,000
FY2002-FY2003: SSN
NF
None
Sec. 520E-2
Mental and Behavioral Health Services on Campus. Grants to institutions of
higher education to enhance services for students with mental and behavioral health
problems, such as depression, substance abuse, and suicide attempts.
2000
FY2005: $5,000,000
FY2006: $5,000,000
FY2007: $5,000,000
$4,975,000
2005-2010
Sec. 520F
Centers for Emergency Mental Health. Grants to support designation of
hospitals and health centers as Emergency Mental Health Centers.
2000
FY2001: $25,000,000
FY2002-FY2003: SSN
NF
None
CRS-28
FY2016-FY2010:
$150,000,000 each year
SAMHSA: Agency Overview and Reauthorization Issues
PHSA
Section
Title and Program Description
Year
Created
Authorization of
Appropriations
Actual FY2010
Funding
Years Funded
Since 2000
Sec. 520G
Grants for Jail Diversion Programs. Grants to states and tribal organizations to
promote the transformation of systems to improve services for justice-involved adults
with mental illness. Grantees are expected to act through agreements with other
public and nonprofit entities to develop and implement programs to divert individuals
with a mental illness from the criminal justice system to community-based services.
2000
FY2001: $10,000,000
FY2002-FY2003: SSN
$6,684,000
2002-2010
Sec. 520H
Improving Outcomes For Children and Adolescents Through Services
Integration Between Child Welfare and Mental Health Services. Grants to
states and tribal organizations to provide integrated child welfare and mental health
services for children and adolescents in the child welfare system or at risk for
becoming part of the system, and for parents or caregivers with a mental illness or a
mental illness and a co-occurring substance abuse disorder.
2000
FY2001: $10,000,000
FY2002-FY2003: SSN
NF
None
Sec. 520I
Grants for the Integrated Treatment of Serious Mental Illness and Cooccurring Substance Abuse. Grants to provide integrated treatment services for
individuals with a serious mental illness and co-occurring substance abuse disorder.
2000
FY2001: $40,000,000
FY2002-FY2003: SSN
NF
None
Sec. 520J
Mental Health Training Grants. Grants for training school and emergency
services personnel to enhance awareness and identification of mental illness.
2000
FY2001: $25,000,000
FY2002-FY2003: SSN
NF
None
Sec. 520K
Awards For Co-locating Primary And Specialty Care In Community-Based
Mental Health Settings. Grants to community mental health programs for
demonstration projects to provide coordinated and integrated services to adults with
mental illnesses who have co-occurring primary care conditions and chronic diseases
through the co-location of primary and specialty care services in community-based
mental and behavioral health settings.
2010
FY2010: $50,000,000
FY2011-FY2014: SSN
NF
None
Secs. 521535
Projects for Assistance in Transition from Homelessness (PATH). Grants to
states to provide outreach, mental health and other support services to homeless
people with serious mental illness. Outreach is focused on homeless individuals who
are not pursuing needed mental health treatment on their own.
1990
FY2001-FY2003:
$75,000,000 each year
$65,047,000
2002-2010
Secs. 561565
Comprehensive Community Mental Health Services for Children with
Serious Emotional Disturbances. Six-year grants to states and tribal organizations
to implement, improve and expand systems of care to meet the needs of children with
serious emotional disturbances and their families. This approach emphasizes culturally
competent care, family driven and youth guided practice, and multi-agency
collaboration.
1992
FY2001: $100,000,000
FY2002-FY2003: SSN
$121,316,000
2000-2010
Sec. 581
Children and Violence. Grants to fund local communities to assist children in
dealing with violence. (Funds are awarded under the Department of Education’s Safe
Schools/ Healthy Students program.)
2000
FY2001: $100,000,000
FY2002-FY2003: SSN
$94,502,000
2002-2010
CRS-29
SAMHSA: Agency Overview and Reauthorization Issues
PHSA
Section
Year
Created
Title and Program Description
Authorization of
Appropriations
Actual FY2010
Funding
Years Funded
Since 2000
Sec. 582
Grants to Address the Problems of Persons Who Experience Violence and
Related Stress (Child Traumatic Stress Initiative). Grants to improve
treatment and services for children and adolescents who have experienced traumatic
events. Addresses child trauma issues by creating a national network of grantees that
work collaboratively to develop and promote effective community practices for
children and adolescents exposed to a wide array of traumatic events.
2000
FY2001: $50,000,000
FY2002-FY2006: SSN
$40,800,000
2002-2010
Secs. 19111920
Community Mental Health Services Performance Partnership Block
Grants. Formula grants to states to support community mental health services for
adults with serious mental illness and children with serious emotional disturbance.
1992
FY2001: $450,000,000
FY2002-FY2003: SSN
$399,735,000
2000-2010
P.L. 99-319
Protection and Advocacy for Individuals with Mental Illness (PAIMI).
Formula grants to support independent protection and advocacy program in each
state. PAIMI programs help protect individuals with mental illness from abuse, neglect,
and violations of their civil rights. The programs investigate and use legal and other
remedies to correct verified incidents.
1986
FY1992: $19,500,000
FY1993-FY2003: SSN
$36,380,000
2000-2010
$79,197,000
2000-2010
Other Authorities
Sec. 501
Program Management. Funding to support SAMHSA’s staff who plan, direct, and
administer the agency’s programs.
1992
Not Applicable
Sec. 506A
Alcohol and Drug Prevention or Treatment Services for Indians and Native
Alaskans. Grants to provide alcohol and drug prevention or treatment services for
Indians and Native Alaskans.
2000
FY2001: $15,000,000
FY2002-FY2003: SSN
NF
None
Sec. 506B
Grants for Ecstasy and Other Club Drugs Abuse Prevention. Grants to carry
out education and other community-based programs to prevent abuse of “club drugs”
by youth.
2000
FY2001: $10,000,000
Subsequent years: SSN
NF
None
P.L. 111-148,
Sec. 10221
Indian Tribes Access to SAMHSA Grants. To simplify the grant application
process for Indian tribes and tribal organizations, and to ensure that state grant
funding is proportionately directed to serve the Indian population in the state.
2010
SSN (no years specified)
NF
None
P.L. 111-148,
Sec. 10221
Indian Youth Life Skills Development Demonstration Program.
Demonstration program to test the effectiveness of a culturally compatible, schoolbased, life skills curriculum for the prevention of Indian and Alaska Native adolescent
suicide.
2010
FY2010-FY2014:
$1,000,000 each year
NF
None
Source: SAMHSA budget justification documents, FY2000-FY2011.
Notes: SSN = such sums as may be necessary; NF = not funded.
a. There are two sections 514 in the PHSA. The first (substance abuse treatment services for children and adolescents) was added by Sec. 3104 of P.L. 106-310; the second
(methamphetamine treatment) was added by Sec. 3632 of the same law.
CRS-30
SAMHSA: Agency Overview and Reauthorization Issues
Table A-2. SAMHSA Funding, FY2000-FY2011
(dollars in millions)
FY2000
FY2001
FY2002
FY2003
FY2004
FY2005
FY2006
FY2007
FY2008
FY2009
FY2010
Request
FY2011
Substance Abuse Block Grant
1,600
1,665
1,725
1,754
1,779
1,776
1,757
1,759
1,759
1,779
1,799
1,799
PRNS Treatmenta
214
256
291
317
419
422
399
399
400
412
453
487
PRNS Preventiona
147
175
197
197
199
199
193
193
194
201
202
223
Prescription Drug Monitoring
0
0
0
0
0
0
0
0
0
2
2
2
Subtotal, Substance Abuse
1,961
2,108
2.213
2,268
2,397
2,397
2,349
2,350
2,353
2,394
2,455
2,510
Mental Health Block Grant
356
420
433
437
434
433
428
428
421
421
421
421
PATH Homeless Formula Grant
31
37
40
43
50
55
54
54
53
60
65
70
PRNS Mental Healtha
136
203
230
245
241
274
263
263
299
344
362
374
Children’s Mental Health Services
83
92
97
98
102
105
104
104
102
108
121
126
Protection and Advocacy
25
30
32
34
35
34
34
34
35
36
36
36
Subtotal, Mental Health
631
782
832
857
862
901
883
884
911
969
1,005
1,028
Program Management
59
88
91
87
92
94
92
93
93
100
102
136
Emergency Response and Recovery
0
28
10
0
0
0
0
0
0
0
0
0
St. Elizabeth’s Hospital
0
0
0
0
0
0
0
0
0
1
1
0
Data Evaluation
0
0
0
0
0
0
0
0
0
3
0
0
2,651
2,966
3,146
3,212
3,351
3,392
3,324
3,327
3,356
3,466
3,563
3,674
Substance Abuse
Mental Health
TOTAL
Source: SAMHSA budget justification documents, FY2000-FY2011.
Notes: Funding includes direct SAMHSA appropriations and PHS evaluation set-aside funds (i.e., funds transferred by the HHS Secretary to SAMHSA, pursuant to PHSA Sec. 241).
a. PRNS = Programs of Regional and National Significance. These budget lines include funding for programs created under general (i.e., PRNS) authority, and programs with
specific PHSA authorizations. Note that the Children’s Mental Health Services Program (PHSA Secs. 561-565) has its own budget line.
CRS-31
SAMHSA: Agency Overview and Reauthorization Issues
Appendix B. SAMHSA National Outcome Measures
Source: SAMHSA (http://www.nationaloutcomemeasures.samhsa.gov/NOMS.aspx?menuID=2&font=).
Congressional Research Service
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SAMHSA: Agency Overview and Reauthorization Issues
Appendix C. Useful SAMHSA Resources
SAMHSA Website: http://www.samhsa.gov
SAMHSA Grant Awards by State: http://www.samhsa.gov/statesummaries/index.aspx
FY2011 Budget Justification: http://samhsa.gov/Budget/FY2011/SAMHSA_FY11CJ.pdf
National Outcome Measures: http://www.nationaloutcomemeasures.samhsa.gov
2000 Reauthorization Language: http://www.samhsa.gov/legislate/Sept01/childhealth_toc.htm
Center for Mental Health Services: http://www.samhsa.gov/about/cmhs.aspx
Center for Substance Abuse Prevention: http://www.samhsa.gov/about/csap.aspx
Center for Substance Abuse Treatment: http://www.samhsa.gov/about/csat.aspx
Center for Behavioral Health Statistics and Quality: http://www.samhsa.gov/about/cbhsq.aspx
SAMHSA Report on Co-occurring Disorders: http://www.oas.samhsa.gov/CoD/CoD.pdf
SAMHSA Report on Performance Partnerships:
http://www.nationaloutcomemeasures.samhsa.gov/./PDF/performance_partnership.pdf
SAMHSA Funding Opportunities: http://www.samhsa.gov/grants/
Garrett Lee Smith Grantee Activities: http://www.sprc.org/grantees/statetribe/desc/
showAllState.asp (state grantees)
http://www.sprc.org/grantees/statetribe/desc/showAllTribal.asp (tribal grantees)
http://www.sprc.org/grantees/campus/desc/show_alldescription.asp (campus grantees)
Author Contact Information
(name redacted)
Specialist in Health Policy
/redacted/@crs.loc.gov, 7-....
Acknowledgments
This report was coauthored by Bonnie L. Norton, Presidential Management Fellow, who is no longer at
CRS.
Congressional Research Service
33
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