Guidelines for Testimony

Join Together's policy panel on state systems is investigating the role that state governments can play in improving drug and alcohol prevention and treatment, with particular emphasis on state level organization, financing and leadership.

The panel will present state leaders and concerned citizens with practical suggestions for organizational structures that foster leadership, effective policy development and collaboration, best clinical practice, and appropriate levels of funding to address their state’s treatment and prevention challenges.

Background

Individuals with substance use disorders don't just drive the expenses and activities of state treatment and prevention agencies. Work by agencies responsible for criminal justice, child welfare, public health, mental health, and education are all affected by these problems. 

In fact, substance use disorders are responsible for about 13% of all state expenditures, not the 0.5% that is allocated for substance use treatment and prevention. However, drug and alcohol policy, treatment and prevention rarely get the attention they deserve at the state level.

State Models

The structure selected by a state has significant implications for the clinical models used to address substance use disorders. Only three states currently have substance use treatment and prevention agencies that are free standing and report directly to the governor. Several other organizational models have emerged in recent years, and are now being used by most states. 

This policy panel is interested in testimony about the pros and cons of the alternative models that seem to be in use or emerging, including:

1. A behavioral health model with substance use disorder treatment integrated with a mental/behavioral health agency.
2. A specialty substance use disorder treatment system that has its own, freestanding agency.
3. A medical care model in which organization and financing for substance use disorders are included in other state funded medical care. (The new IOM report, "Improving the Quality of Health Care and Mental and Substance-Use Conditions," advocates for this model.)

Multi-Agency Coordination

Any effective state level approach to drug and alcohol problems requires substantial coordination among different agencies and funding streams. A variety of coordinating mechanisms are available to states including:

1. A single state agency (SSA) located within a "superagency" that deals with many of the related issues.
2. A drug czar in the governor's office with or without actual budget oversight.
3. A cabinet-level SSA with budgetary or contracting relations to other departments.
4. Working-level collaboration among several agencies (i.e. collaboration between criminal justice, child welfare and the state substance use disorder agency).
5. Letting the providers and clients coordinate their own treatment and related needs through mechanisms like case management, vouchers, or mixed funding streams generated at the provider level.

The policy panel is interested in testimony about these and other approaches to collaboration and leadership at the state level. Examples of the strengths and weaknesses of these or other alternatives will be particularly helpful. The panel is interested in recommendations about leadership, organization and coordination, based on direct experience and observations of these models and others. Among additional questions to consider:

Financing

• How should states coordinate or meld separate funding streams that address similar problems and populations?
• How should providers be paid to get the best results for patients? Should there be contracts for treatment organizations to provide service with or without performance incentives? Should there be vouchers to individuals? Should payments be a part of public and private medical insurance?
• How should the essential support services for individuals with substance use disorders be paid for and provided including housing, child support,
  job training, food support, etc.

Workforce Development

Workforce problems cut across multiple agencies and groups, including treatment providers, probations officers, social workers, counselors and managers.

• What can the state do to build workforce capacity, competence and endurance?
• What role should the states play in helping consumers understand and choose among the various kinds of providers who offer substance use disorder treatment?
• What could be the role of state universities in training the prevention and treatment workforce?

Leadership

• What can a state do to recruit and retain dynamic, effective leadership for state agencies and providers?
• Does the location of the state agency matter in getting and keeping strong leadership?
• What should be the role and responsibility of the governor? Do “czars” or some other leadership post close to the governor make any difference in mobilizing resources, collaboration and effective policy?

Prevention

States spend money on alcohol and drug prevention through a number of agencies. For example, state education agencies administer major prevention education programs. In many states, Alcohol Control Boards, Highway Safety Bureaus, National Guard Departments, and other agencies have prevention related activities. State level policies on alcohol taxes, licensing hours and locations, limited licenses for young drivers and other issues also play a major role in preventing harms from alcohol misuse.

The panel is interested in testimony describing the pros and cons of alternative state level mechanisms for improving prevention services and policies. Examples of actual programs and policies will be particularly helpful. The panel is also interested in hearing ideas about how to develop and retain dynamic and effective leadership for prevention.

Measurement issues

In many ways, governments and societies get what they measure. The panel is interested in testimony that will provide practical guidance on what state level agencies should measure and report in order to improve substance use disorder treatment and prevention services and policies. Examples of actual reporting schemes and their results will be particularly helpful.