Testimony

April 29, 2004

Mr. Chairman and Members of the Subcommittee, I am pleased to present the President's Fiscal Year 2005 budget request for the Substance Abuse and Mental Health Services Administration (SAMHSA) within the U.S. Department of Health and Human Services (HHS). Overall, the President has proposed a 6 percent increase in both mental health and in substance abuse prevention and treatment. The FY 2005 budget request is $3.6 billion for SAMHSA. This is a net increase of $199 million over FY 2004 and is an increase that will allow SAMHSA to continue working toward fulfilling our vision and mission. Our vision of "a life in the community for everyone" and our mission to "build resilience and facilitate recovery" are clearly aligned with the priorities of both President Bush and Health and Human Services (HHS) Secretary Tommy G. Thompson.

Our collaborative efforts with our Federal partners, States and local communities, and faith-based organizations, consumers, families and providers are central to achieving both our vision and mission. Together, we are working to ensure that the 22 million Americans with a serious substance abuse problem, the 17.5 million Americans with serious mental illness, and the 4 million Americans with co-occurring serious mental illness and substance abuse problems have the opportunity for fulfilling lives that include a job, a home, and meaningful relationships with family and friends.

To better serve those with mental illnesses, substance use disorders, and co-occurring disorders, a true partnership of equals has emerged. Our common goal is to more rapidly deliver research to the communities that provide services. The partnering activities of SAMHSA and our HHS sister agencies, including the National Institutes of Health, and the Office of Safe and Drug Free Schools at the Department of Education, include ongoing workgroups and collaborative initiatives and programs. As a service agency, it only made sense for SAMHSA to more fully engage the pertinent NIH research agencies - the National Institutes on Drug Abuse (NIDA), The National Institute on Alcohol Abuse and Alcoholism (NIAAA) and the National Institute of Mental Health (NIMH) -- to advance the practical application of the immense scientific knowledge base they have created and continue to create.

SAMHSA and the consumers of the services we support rely on the research expertise of the Institutes to glean the evidence of what works. We will continue to rely on future research activities surrounding the genome, neurotransmitters, new medications, and new behavior therapies, among many others. We are focused on putting the knowledge to work because knowledge without application loses its value, and service without evidence-based reasoning is not solid service.

The closer working relationship between SAMHSA and the Institutes that has evolved over the past several years is invaluable and, many would argue, long overdue. The generations lost while we have tried to cross what the Institute of Medicine has coined the "Quality Chasm" between the development and implementation of new therapies are a loss that this Administration will no longer accept. I concur, and I am thankful for that. I am also thankful for the tremendous initiative, leadership and genuine interest in achieving full cooperation that the Institutes and SAMHSA have demonstrated. Together we have constructed a conceptual and visual depiction of what has become known as the "Science to Services Cycle." There are three distinct phases of the Cycle and their corresponding activities that represent the movement of scientific knowledge into actual clinical practice. The three phases are: (1) Research and Development - which clearly is accomplished through the Institutes; (2) Dissemination and Implementation - which is shared by SAMHSA and the Institutes; and (3) Monitoring and Feedback - which rests with SAMHSA as the service agency.

I want to assure you that we have moved beyond this conceptual framework and have begun implementation. For example, SAMHSA and NIMH recently funded one-year grants to mental health services providers to support activities toward implementing evidence-based practices in their communities. We are working with NIDA through our Addiction Technology Transfer Centers (ATTCs) to encourage the adoption of evidence-based practices by alcohol and drug abuse treatment programs and providers. We are working with NIAAA on ways to screen, identify, and treat patients in hospital emergency departments for alcohol problems. And at SAMHSA we have established standard grant announcements that further implement the "Science to Service" cycle through the use of best practices and bringing best practices to scale on a national level. These examples are a few of the ways we are directly working with the Institutes to speed research findings into practice.

The forward progress in streamlining the activities within the three phases of "Science to Services" is demonstrated in SAMHSA's recent successes in readily delivering the best, science-based, research-backed programs to States and local communities that in turn improve services for the consumers of the services we support older adults, adults, young adults, adolescents and children alike.

I am particularly proud to tell you that improving services for all populations, from this nation's elderly down through and including our youngest citizens, is the driving force behind achieving our agency goals - goals which are independent yet interconnected and goals which are clearly outlined in our Matrix of agency priorities. SAMHSA uses the Matrix in the same way that NIH uses its "Roadmap Initiative".

Since this time last year, when it was relatively new, the Matrix has matured into an invaluable tool. It has undergone revisions to reflect current critical issues set forth by all who are linked to ensuring the availability and delivery of mental health and substance abuse treatment services or are receiving these services. I am pleased with the role the Matrix has served. I designed it to take the mystery out of where SAMHSA is headed and to serve as a practical tool to design our budget request that would reflect the agency as a whole rather than as the sum of its three centers, and it has done just that.

The SAMHSA Matrix has produced concrete results by focusing SAMHSA staff and the field on planting a few "redwoods" rather than letting "a thousand flowers bloom." My responsibility as Administrator is to make solid, lasting improvements that will sustain quality consumer service beyond my tenure, establish a better delivery system for the future, and guarantee growth in accountability, capacity and effectiveness. I am proud of our success over the past two and half years since I came to SAMHSA.

I believe the SAMHSA Matrix is the underpinning of our success and has helped us to focus on four solid investments in the future of mental health and substance abuse prevention and treatment services. The President's Budget will allow SAMHSA to:

• Expand substance abuse treatment capacity in new and innovative ways;
• Strengthen our substance abuse prevention efforts and streamline these efforts on a national scale;
• Implement our action agenda to achieve a wholesale transformation of this nation's mental health services delivery system; and
• Transform the current Block Grants in order to improve Sate and federal accountability and increase State flexibility in use of funds.

SAMHSA is committed to manage these major initiatives by providing States with clear but limited requirements and standards for national outcomes data collection and by requiring accountability through performance. A significant function of developing consistent performance measures is to create a basic national data set. Through encouraging the identification of particular domains or "National Outcomes" and related performance measures that are more broad and recovery based than simply reporting numbers of consumers served, or beds occupied, SAMHSA has facilitated the use of data and outcomes to provide information regarding real outcomes for real people. Focusing on this handful of National Outcomes for the Block Grants, as well as for all SAMHSA's major initiatives, will minimize the reporting burden on the States and will enable SAMHSA and the States to effectively monitor client outcomes and help direct systems improvements.

SUSBTANCE ABUSE CLINICAL TREATMENT AND RECOVERY SUPPORT SERVICES

The budget request includes a total of $1.8 billion for the Substance Abuse Prevention and Treatment (SAPT) Block Grant, an increase of $53 million over FY 2004. In FY 2004 we commenced the President's Access to Recovery substance abuse treatment voucher initiative with a $100 million investment. Early indications, based on our technical assistance to date, suggest that almost every State and approximately 80 tribal organizations may apply for these funds. It is already clear that the number of outstanding proposals we receive will by far exceed the amount of funding available. Our FY 2005 budget request doubles funding for Access to Recovery for a total of $200 million, which will provide approximately 15 more ATR grants. These investments advance the President's commitment to expanding drug treatment and recovery support services and increasing accountability in the drug treatment system.

Access to Recovery is based on the knowledge that there are many pathways to recovery. It empowers people with the ability to choose the path best for them - whether it is physical, mental, medical, emotional or spiritual. In particular, we know that for many Americans, treatment services that build on spiritual resources are critical to recovery. Access to Recovery ensures a full range of clinical treatment and recovery support services are available, including the transforming powers of faith. Critically, Access to Recovery delineates a process to monitor and report outcomes in seven domains, discussed later in this testimony, that represent desired outcomes for real people working to attain and sustain recovery. Another key to the successful implementation of the Access To Recovery grant program will be to ensure effective management of the vouchers, including the prevention of waste, fraud and abuse.

While the Access to Recovery program is promising, it is imperative not to lose sight of the importance of preventing addiction in the first place by stopping drug use before it starts.

STRATEGIC PREVENTION FRAMEWORK

We have been working hard to develop a Strategic Prevention Framework to more effectively and efficiently align our prevention resources. As a result, for the first time in years, the proposed budget maintains CSAP's funding level at $196 million. In addition, the Substance Abuse Prevention and Treatment Block Grant investment in prevention increases by $11 million.

Our prevention efforts are aligned with the President's and Secretary Thompson's HealthierUS initiative. HealthierUS is a plan to improve overall public health by capitalizing on the power of prevention. Our goal is to aid Americans in living healthier, longer lives. The President and Secretary Thompson also set aggressive goals to reduce youth drug use in America and I am pleased to report that the data now confirms that the President's two-year goal has been exceeded with an 11 percent reduction in drug use among youth. This is a clear indication that the our work with our many Federal and State partners, along with schools, parents, teachers, law enforcement, religious leaders and local community anti-drug coalitions, is paying off. But our work is far from over, and prevention is key.

Our proposed prevention budget is based on evidence showing that substance abuse prevention is effective. Many of the community programs have adopted science-based substance abuse prevention strategies, and have been evaluated and endorsed by SAMSHA as effective models. These model programs, listed in our National Registry of Effective Programs, yield on average a 25 percent reduction in substance use by program participants. This belief is echoed by NIAAA's recent intensification of research to enhance an understanding of the developmental stages of adolescents in terms of alcohol use and dependence. SAMHSA and our partners are collaborating to prevent underage drinking, which has been a stubbornly persistent problem for years. We have formed a government-wide work group to conduct a thorough review and assessment of existing Federal efforts, areas of need, and opportunities for collaboration to address this problem. Our goal is implementing appropriate steps to create and sustain a strong commitment to reduce underage drinking.

Even before this report was issued, we were hard at work at SAMHSA. We have worked with local communities, Federal partners and national organizations, including Scholastic, Inc., and the Leadership to Keep Children Free, started by NIAAA, to develop the "Reach Out Now" and "Too Smart to Start" programs, which are designed specifically to reach out early, before children start drinking alcohol, and instill refusal and self protection skills that can grow into a lifetime of healthy behaviors. In fact, this week we are sponsoring "Teach-Ins" using the "Reach Out Now" materials in 5th and 6th Grade classrooms throughout the country. Every 5th and 6th Grade teacher in the U.S. received these materials that include a four-page set of lessons and in-class activities for teachers to use and a take-home packet for students and their parents. The Office of Safe and Drug Free Schools and NIAAA has been most helpful in this effort over the years. They have worked with us, not only reviewing the draft materials, but also communicating about them to their constituency groups. It is a working example of how collaborations can be successful.

Another collaboration we have initiated at SAMHSA is the development of a Strategic Prevention Framework, which will guide prevention activities. The Framework conceptualizes prevention as a five step process to promote youth development, reduce risk-taking behaviors, build on assets, and prevent problem behaviors in all areas of a young person's life - at home, at school, and in the community. The five-steps are: (1) Profile needs and response capacity; (2) Mobilize and build needed capacity; (3) Develop a prevention plan; (4) Implement programs, policies and strategies based on what is known to be effective; and (5) Evaluate program effectiveness; sustaining what has worked well.

The FY 2005 budget request includes $85 million for the State Incentive Grant for Substance Abuse Prevention program with a focus on implementing the Strategic Prevention Framework. SAMHSA is collaborating with NIDA to evaluate these new state incentive grants and continues to work with the Institutes to move SAMHSA's Strategic Prevention Framework (SPF) from the vision of a cross-system approach into state and community-based action in mental health promotion and substance use prevention.

The SPF has the potential to bring together stakeholders from across the Federal government. We will continue to work within HHS and also with Departments of Justice, Housing and Urban Development, and Education, the Drug Enforcement Administration, and the White House Office of National Drug Control Policy as we finalize and implement the framework. Each of our programs alone provides a single funding stream - together we can provide an ocean of change.

MENTAL HEALTH SYSTEM TRANSFORMATION

As you may recall, the President appointed a New Freedom Commission on Mental Health in April 2002 to conduct a comprehensive study of our Nation's mental health service delivery system, including public and private sector providers. The Commission submitted its final report to the President in July 2003. The Report found that the nation's mental health care system is beyond simple repair. Instead, it recommended a wholesale transformation that involves consumers and providers, policymakers at all levels of government, and both the public and private sectors. SAMHSA was tasked by the Administration to review the Commission's report and to develop an action agenda to achieve the goals for transformation outlined by the Commission.

Already, in response to the recommendations, the President's proposed FY 2005 budget includes a new initiative to begin the process of transforming mental health care in America. Specifically, the President's budget includes $44 million for State Incentive Grants for Transformation. The goal is to create comprehensive State mental health plans that will improve the use of existing resources to serve people with mental illness.

As we begin the process of transformation, we will continue to support programs that currently support and maintain services for people with mental illnesses and children with serious emotional disturbances. An over-arching component is the Community Mental Health Services Block Grant. We are proposing $436 million in FY 2005 to continue its support to State systems. We also are requesting $30 million for the National Child Traumatic Stress Initiative program. We propose to continue at $95 million the School Violence Prevention Initiative, which includes the Safe Schools/Healthy Students interdepartmental program. And, $11 million is included to support State Mental Health Data Infrastructure Grants. The Children's Mental Health Services Program will continue as one of SAMHSA's flagship programs. The ongoing evaluation of this program has continued to document a solid record of positive outcomes. The President has proposed $106 million in FY 2005, an increase of approximately $4 million over the FY 2004 funding level. We are proposing to continue the Protection and Advocacy Program at almost $35 million in FY 2005. The Projects for Assistance in Transition from Homelessness (PATH) program is proposed for a $5.5 million increase, for a total of just over $55 million.

We are very pleased to propose $10 million in SAMHSA's budget for the Samaritan Initiative. This new program will be jointly funded with the Departments of Housing and Urban Development and Veterans Affairs. It will provide grants to support the full range of services that chronically homeless people need to escape homelessness, including housing, outreach and support services such as mental health services, substance abuse treatment and primary health care.

However, transformation of the mental health system will not be accomplished through change on the margin, but rather through profound change in behaviors and competencies. It is a continuous and long-term process that leads to a different structure, culture, policy, and programs to which the Agency is strongly committed. This change is also needed to fully include a population of consumers that until recently has been virtually overlooked and, more often than not, shuffled around. Those consumers are those who suffer with co-occurring mental and substance use disorders.

CO-OCCURRING MENTAL HEALTH AND SUBSTANCE ABUSE DISORDERS

The FY 2005 budget request includes $22 million for the support of State Incentive Grants for Co-occurring disorders. People with co-occurring disorders face longstanding systemic barriers to appropriate treatment and support services and, until recently have been virtually overlooked. To begin to eliminate these barriers we submitted our National Blueprint for Change Report to Congress on co-occurring disorders in December of 2002. We are now achieving the action steps outlined in the report to Congress.

These actions steps have led to tangible accomplishments including the new SAMHSA funded State Incentive Grant for Co?occurring Disorders; our newly operational Co-Occurring Center for Excellence, which is a national co?occurring disorders prevention and treatment technical assistance and cross?training center that NIDA helped to create through membership of the steering council; and a broadened approach to identify and disseminate known effective programs for the prevention and treatment of co-occurring disorders through our National Registry of Effective Programs.

If we continue to foster these initiatives and further our goals of expanding substance abuse treatment capacity and recovery support services; implementing the strategic prevention framework; transforming mental health care; and improving, we will be simultaneously better serving people in the criminal and juvenile justice systems, those with or at risk of HIV/ AIDS and hepatitis, our homeless, our older adults, and our children and families. While all of the priority areas identified on the Matrix may not be targeted for funding increases, they nevertheless remain foci for SAMHSA's efforts. For example, we will continue to work to divert and prevent recidivism for people with mental and substance use disorders through our collaborations with the Department of Justice. We are expanding our efforts to collaborate with the Administration on Aging to tailor our programs to include the unique and specific needs of older adults. HIV/AIDS and hepatitis often occur with substance abuse and mental illness. Minority communities are especially hard hit. We are continuing to invest $111 million in FY 2005 to prevent and treat mental illness, and substance use disorders in these communities. Some of our most vulnerable populations are still subjected to the use of Seclusion and Restraint. Our national action plan to ultimately eliminate the use of such practices is well underway. And, finally, our neighbors, co-workers and family members can be helped tomorrow, if need be, through today's programs to plan for Disaster Readiness and Response.

ACCOUNTABILITY AND PERFORMANCE

Although I can tell you about our progress and provide real examples of how SAMHSA has and plans to continue improving what we do and how we do it, we are committed to creating a yardstick for measuring and managing performance. SAMHSA initiated a process to develop a data strategy in August 2003. This process has to date involved a thorough examination of SAMHSA's data collection and analysis systems. The goal of the strategy is to take steps now to ensure that decisions related to SAMHSA's goals of Accountability, Capacity and Effectiveness are based on the most comprehensive and accurate information available.

An essential component of SAMHSA's data strategy is development of "National Outcome" and related National Outcome Measures, " that I mentioned earlier. Through collaboration with the States we have identified seven key data domains which when finalized will become intrinsically valuable in measuring how effective the implementation of science-based services is in communities across the nation. Theses seven key domains are: (1) abstinence from drug use and alcohol abuse, or decreased mental illness symptomatology; (2) increased or retained employment and school enrollment; (3) decreased involvement with the criminal justice system; (4) increased stability in family and living conditions; (5) increased access to services; (6) increased retention in services for substance abuse treatment or decreased utilization of psychiatric inpatient beds for mental health treatment; and (7) increased social connectedness to family, friends, co-workers and classmates.

These national outcome measures are already being implemented through the Access to Recovery program. Ultimately they will be aligned across all of SAMHSA's programs, including the Community Mental Health Services Block Grant and the Substance Abuse Prevention and Treatment Block Grants. The national outcome measures are an attempt to provide greater flexibility and accountability without increasing state reporting requirements. Ultimately this will ensure the data collected is relevant, useful and completes the Science to Services cycle.

As a distinct underlying responsibility of SAMHSA's work as a service agency, our FY 2005 budget proposes a $66 million investment in data infrastructure and related technical assistance to the States for a cumulative total of $277 million from FY 2001 to FY 2005. This is in direct response to our new core operating mechanism that more closely looks at what data we are collecting, why, and how it can best be used to manage and measure performance. Our Data Vision strategy for putting data to work for us through controlled measures to make informed decisions is well underway.

SAMHSA is the primary source of national data on the prevalence, treatment, and consequences of substance abuse in the United States through our National Survey on Drug Use and Health. SAMHSA also regularly collects data on drug-related emergency room visits and drug-related deaths through our Drug Abuse Warning Network (DAWN) and is the national source of information on the Nation's substance abuse treatment system through our Drug and Alcohol Services Information System (DASIS).

The accomplishments that will result from the opportunities included in this year's proposed budget will help us meet the urgent need for our systems of service to fully evolve into systems of science-based, integrated treatment and supportive services. Our direction, vision, mission and Matrix respond to today's knowledge that with appropriate treatment and supportive services, people with mental illness, substance abuse disorders and co-occurring disorders can and do recover. We also know that prevention is paramount in keeping illness from grabbing hold in the first place.

Mr. Chairman and Members of the Subcommittee, thank you for the opportunity to appear today. I will be pleased to answer any questions you may have.

Charles G. Curie, M.A., A.C.S.W. Administrator
Substance Abuse and Mental Health Services Administration
U.S. Department of Health and Human Services

Charles G. Curie was nominated by President George W. Bush and confirmed by the U.S. Senate in October 2001 as Administrator of the Substance Abuse and Mental Health Services Administration (SAMHSA). As SAMHSA Administrator, Curie reports to Health and Human Services Secretary Tommy G. Thompson and leads the $3.2 billion agency responsible for improving the accountability, capacity and effectiveness of the Nation's substance abuse prevention, addictions treatment and mental health services.

Articulating the vision of "a life in the community for everyone," Curie has charted a new course for SAMHSA. To realize this vision Curie has redefined SAMHSA's mission as "building resilience and facilitating recovery." He has created an Agency matrix of priorities and principles to guide program development and resource allocation. SAMHSA's new direction is based on the premise that people of all ages, with or at risk for mental or substance abuse disorders, should have the opportunity for a fulfilling life that includes a job, a home, and meaningful personal relationships with friends and family.

Curie has over 25 years of professional experience in mental health and substance abuse services field. His core commitment to ensuring that people with addictive and mental disorders have the opportunity for full participation in American society has earned him national recognition and acclaim.

Prior to his confirmation as SAMHSA Administrator, Curie was appointed by then Governor Tom Ridge as Deputy Secretary for Mental Health and Substance Abuse Services for the Department of Public Welfare in Pennsylvania. During his tenure, Curie implemented a nationally recognized mental health and drug and alcohol Medicaid managed care program and streamlined fractured service delivery systems. He also established and implemented a policy to reduce and ultimately eliminate the use of seclusion and restraint practices in the state hospital system. This program won the 2000 Innovations in American Government Award sponsored by Harvard University's John F. Kennedy School of Government, the Ford Foundation, and the Council on Excellence in Government.

Before his service in the Ridge Administration, Curie was the Director of Risk Management Services for Henry S. Lehr Inc. in Bethlehem, PA; President/CEO of the Helen H. Stevens Community Mental Health Center in Carlisle, PA; and Executive Director/CEO of the Sandusky Valley Center in Tiffin, Ohio. Curie is a native of Indiana and a graduate of Huntington College. He holds a Masters Degree from the University of Chicago School of Social Service Administration and is also certified by the Academy of Certified Social Workers.

Department of Health and Human Services
Office of Budget
William R. Beldon

Mr. Beldon is currently serving as Deputy Assistant Secretary for Budget, HHS. He has been a Division Director in the Budget Office for 16 years, most recently as Director of the Division of Discretionary Programs. Mr. Beldon started in federal service as an auditor in the Health, Education and Welfare Financial Management Intern program. Over the course of 30 years in the Budget Office, Mr. Beldon has held Program Analyst, Branch Chief and Division Director positions. Mr. Beldon received a Bachelor's Degree in History and Political Science from Marshall University and attended the University of Pittsburgh where he studied Public Administration. He resides in Fort Washington, Maryland.

Last revised: April 29, 2004

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