Delay in Funding Federal Agency Puts Ambitious Agenda on Hold

Congress needs to reauthorize the leading federal agency involved in mental health treatment to ensure that the latest research is driving federal policy in this area. However, that approval is unlikely to happen until legislators wrap up work on health care reform late this year.

Congressional staff have notified mental health advocates that the long-delayed reauthorization of the Substance Abuse and Mental Health Services Administration (SAMHSA) will not occur this year because health care reform legislation “has sucked up all the air in the room.” The SAMHSA reauthorization—and a review of its mission and programs—is now not expected until 2010.

SAMHSA, an agency of the Department of Health and Human Services, supports treatment for psychiatric illnesses, including substance abuse disorders, through grants to and contracts with states and local communities. The agency received a five-year reauthorization in 2000.

Rep. Patrick Kennedy (D-R.I.) told mental health advocates at a September meeting that the reauthorization is not expected to advance until after enactment of health care reform legislation. No reauthorization bills have yet been introduced, though draft legislation has circulated on Capitol Hill.

The main obstacle to Congress renewing the agency's authorization is that much of the same staff who would craft such legislation are focused exclusively on enacting an overhaul of the nation's health care system,“ so they haven't had a chance to work on” SAMHSA reauthorization, Julio Abreu, senior director of government affairs for the advocacy group Mental Health America, told Psychiatric News.

The reauthorization is critical, say mental health advocates, to incorporating the latest research into the agency's approach to mental health services funding and to paring programs that have underperformed or were too poorly funded to achieve their goal.

“It's helpful to have Congress say 'These are the priorities for this agency,'” said William Emmet, director of the Campaign for Mental Health Reform, of which APA is a member, in an interview with Psychiatric News.

Among the major developments with which SAMHSA is involved are the recommendations of the 2003 President's New Freedom Commission Report on Mental Health. The commission's report emphasized the urgent need to“ transform” the entire public mental health system to focus on recovery and increase patient and family participation in decision making.

Among other recent developments that are on the agency's agenda is the release of the landmark report by the Institute of Medicine (IOM) titled“ Preventing Mental, Emotional, and Behavioral Disorders Among Young People: Progress and Possibilities” (Psychiatric News, April 3). The February IOM report concluded that the prevention of mental illness and promotion of mental health are scientifically feasible, and it called for enhancing the translation of the science into practice.

The newer research and examinations of best practices could help the agency focus its limited funds on programs that have the best evidence-based record and proven effectiveness, said mental health advocates.

“The time is ripe for taking these studies and applying them to SAMHSA,” Abreu said.

A major hurdle that the agency's reauthorization will face is a struggle over federal funding for faith-based treatment programs. Democratic leaders in the House of Representatives wrote to the Senate committee with SAMHSA oversight authority in the last Congress opposing the provision in the SAMHSA reauthorization that would fund faith-based groups that provide mental health and substance use treatment services, advocates noted.

Senate Republicans and former President George W. Bush had insisted on the inclusion of “charitable choice” provisions in SAMHSA reauthorization that would allow such religion-based treatment groups to require patients seeking treatment to participate in mandatory religious activities. The provisions also would allow those organizations to limit employment to people who are members of the organization or who profess their faith as defined by that organization.

Charitable choice drew criticism from many secular groups that, based on issues of separation of church and state, opposed use of federal dollars by faith-based organizations, the programs' mandatory religious activities, and the restrictions on employment.

The issue has far-reaching consequences because many substance abuse treatment programs have a religious component.

“All treatments today are based on a spiritual element, which is essential,” Kennedy stated. “At the same time, we have to be sensitive to the Constitution,” in terms of required separation of church and state.

The conflict led Congress to back off the reauthorization last year, and it remains unresolved.

Another obstacle to the agency's reauthorization may be its lack of a permanent director. The agency has been without a leader since Terry Cline, Ph.D., left in August 2008. Eric Broderick, D.D.S., has served as SAMHSA's acting administrator since then. Any new permanent administrator is likely to hold up the reauthorization to first review the agency's needs and the priorities that the nominee would want the reauthorization to emphasize, according to advocates.

Beyond the higher-profile challenges to reauthorization are more mundane but significant points of contention. During Congress's last SAMHSA reauthorization review, some proponents sought to merge SAMHSA's now-separate block-grant funding for mental illness and substance use. The late Sen. Edward Kennedy countered that flexibility was the key and sought guidelines to ensure that local clinicians have the freedom to treat both substance abuse and other mental health problems (Psychiatric News, June 1, 2007).

The IOM report “Preventing Mental, Emotional, and Behavioral Disorders Among Young People: Progress and Possibilities” is posted at<www.iom.edu/CMS/12552/45572/64120.aspx>. The President's New Freedom Commission Report on Mental Health is posted at<www.mentalhealthcommission.gov>.▪