Editor’s note: At press time, the House and Senate have not issued funding decisions on the proposed Access to Recovery program. For the latest information, visit www.samhsa.gov, www.house.gov, and www.senate.gov, and contact your policy-makers.

In his address and formal budget proposal in February, Bush presented a request to Congress for $200 million in each of the next three years for an Access to Recovery (formerly Recovery Now) program. The administration estimates that 100,000 drug and alcohol users need but cannot get treatment, based on the Substance Abuse and Mental Health Administration (SAMHSA) 2001 National Household Survey on Drug Abuse released last October. “Based upon $200 million, we should be able to serve about 100,000 people — annual treatment averages $2,000,” SAMHSA Administrator Charles Curie told Counselor.

How vouchers would work
Under Bush’s plan, individuals seeking help first would get assessed, and then would receive a voucher and guidance on treatment options. In other words, they would choose their own treatment from available hospitals, clinics, and individual providers.

“The program is designed to improve quality, expand services and provide a greater number of providers,” explained John Walters, director of the White House Office of National Drug Control Policy. Individuals in need of treatment could be assessed at a variety of locations: physicians’ offices, emergency rooms, workplaces, the criminal justice system, and schools. “Wherever you have people who have a need, you have referral directly to a list of providers,” said Walters. Furthermore, “vouchers allow us to welcome people” who can provide treatment but don’t work directly with the federal government, and will help cut time delays between diagnosis and treatment, he added.

Vouchers could fund such programs as medical detoxification, in-patient and outpatient services, residential treatment, peer support, relapse prevention, and case management. Depending on individuals’ needs, health care providers, employers, and schools could also participate, creating competition among providers.

Under the law of supply and demand, vouchers should stimulate the supply of providers, the administration figures. For example, a center receiving a grant to serve 10 clients will prepare 10 beds; but with vouchers, the administration believes, providers would increase their capacity to serve clients who come in with payments in hand.

Walters added that vouchers would save the government money because programs typically operate with utilization rates between 75 and 80 percent, and the government winds up spending money for slots not being used. Vouchers solve that problem because the government would pay only for people receiving treatment.

“It is going to be very important to have accurate professional assessment and diagnosis determining the best treatment for that individual and that the individual be given options,” Curie explained. “If they need an intensive outpatient program, they’ll receive a listing of credentialed intensive outpatient providers.”

Standards for providers
Providers would have to prove effectiveness to remain eligible, though it may take a while for states or the federal government to develop an accountability system, Curie said. Such a system might start with a scorecard rating client satisfaction and outcome. Eventually, states will rank client outcomes including abstinence, employment, maintaining stabilized housing, pursuit of educational goals, avoidance of the criminal justice system, and connectedness to the community. “Our goal would be to focus on those outcome measures,” Curie explained. “If providers demonstrate the client has attained them, they’d get paid the full rate and perhaps a bonus. If they are not able to demonstrate outcomes over time, the voucher program could work one of two ways. Prospective clients may not choose to go to them. [Or] over time, as potential providers are monitored, if it doesn’t look like they are achieving outcomes, we will review their eligibility.”

Curie acknowledged that the government will have to develop realistic baselines to prevent “creaming,” the process of taking the easier cases to increase success rates. The plan also calls for federal monitoring of the program to ensure effectiveness and develop standards for providers. “States will be required to submit as part of their application a detailed plan to broaden the base of providers and ensure that a wide variety of provider organizations, including faith-based organizations, are eligible for voucher reimbursement,” Curie stated. States also need to develop screening, assessment, referral, and placement processes for all clients.

Funding the program through states
Although Congress must appropriate the money, SAMHSA has authority under existing legislation to operate the program, Curie asserted. He testified to Congress in February that he expects to ask governors to apply for money in late summer or early fall. “The request for applications would be issued after the money is appropriated,” Curie told Counselor.
SAMHSA has not decided if it will fund every state that applies and does not know if every state will apply. While larger states would probably receive bigger shares, SAMHSA has not determined a funding formula. The plan calls for allowing states to partner with local governments and private entities to administer the program or parts of it. And states will not have to operate programs statewide. “Within a state, the program may be targeted to areas of greatest need or areas where there is a high degree of readiness to implement such an effort,” Curie testified.

States will be able to design different types of vouchers for different services — one certificate may be good for a counselor, another for inpatient treatment, for instance. Providers could get reimbursed for their costs up to a state limit for different types of services. “These cost ranges will be determined by an analysis of historic cost data,” Walters said. “Some of the specifics we’ll work out with the individual states.” Asked if clients could transfer vouchers from one provider to another, he replied: “We’d like to see money follow the person that needs services. If a particular provider is not effective or not right for the person, we would like [to see a transfer]. If a person is not in recovery, we’d like to see him move to a provider who can get him into recovery.”

Views from inside Congress
Members of Congress interviewed said that they like the idea of increasing federal support for drug treatment, but several questioned vouchers.

Rep. Joe Pitts (R-PA) told Counselor that rather than try something new, “we should fund programs that have proven effective. I don’t know about new experimental programs when you have programs with an 86 percent success rate.”

Rep. Steny Hoyer (D-MD) said that he would have to hear more about the voucher idea before judging it. “We obviously need more money spent on drug problems. ... Six hundred million sounds like a lot of money but when you divide it among the whole country, the sums become much smaller,” Hoyer told Counselor. “Right now, the waiting list is too long for those who seek or are referred by courts for drug rehabilitation.”

Sen. Ted Kennedy (D-MA) said to Counselor, “The idea that we deal with the victims, the demand side of the war on drugs, is enormously [positive].”

Yet the eligibility of faith-based organizations for reimbursement under the plan already has caused controversy. Ranking Democrat on the House Judiciary Subcommittee on the Constitution Rep. Jerrold Nadler (D-NY) said, “It is a violation of the First Amendment to give money to churches.... If they say the way to cure addiction is through faith in God or faith in Jesus, then that’s fine, but it should not be done with government money.”

Nadler warned that religious providers will not need licenses, and that once money is sent to churches, auditors must be sent — and the government is “looking over churches’ backs.” He said that he could support the idea if vouchers did not go directly to churches. Instead, churches could form a separate nonprofit to provide services “but they cannot discriminate on whom they hire or whom they serve.”

Curie responded that the government would not fund religious programs direcly — it would give vouchers to consumers, overcoming constitutional barriers. “Because we’re giving people a choice, we’re not forcing faith or religion on anyone. Vouchers have been demonstrated as a way to address that issue,” Curie said. He expects states, as part of their credentialing process, to ensure that faith-based providers do not discriminate in hiring or taking clients.

Questions remain
Will Congress appropriate the money given the need to pay for the reconstruction of Iraq, a sluggish economy, a mounting deficit, and demands for other domestic spending? Walters promised that vouchers would be funded through “new money. We are not taking money from other programs.”

Both houses of Congress lie in the hands of Republicans basically friendly to Bush’s philosophy. So today it looks like The program faces two hurdles before getting a try: whether appropriators can find the money, and how many governors will find the extra money worth the effort. The news will be worth following.

Charles Pekow, MJ, has been a freelance Washington writer for more than 12 years. His work has appeared in the Washington Post, International Herald-Tribune, Washington Times, and many other journals. He won the Washington Writing Prize from Washington Independent Writers in 2003 for best reported story.

This article is published in Counselor,The Magazine for Addiction Professionals, August 2003, v.4, n.3, pp. 54-55, 69.

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