The Substance Abuse and Mental Health Services Administration (SAMHSA) recently offered a first glimpse of what President Bush's addiction-treatment voucher program might look like in practice. But the Senate dealt the proposal a heavy blow when it refused last week to fund the program, citing tight budgets and concerns about implementation.

President Bush unveiled the $600-million voucher program, initially dubbed Recovery Now, during his State of the Union address in January. In its FY2004 budget, the administration proposed spending $200 million on the newly renamed Access to Recovery program, which would provide vouchers that clients with alcohol and other drug problems could redeem at their treatment center of choice, including faith-based programs.

The budget plan approved by the House of Representatives' Appropriations Committee during the last week of June expressed support for the voucher program and earmarked $100 million for the program. In its conference report, the appropriations committee said it expects that all addiction-treatment programs funded with federal dollars will be subject to performance measurement. The House also said that the money should be used by SAMHSA to fund a pilot study before full implementation of the Access to Recovery program.

The Senate took a dimmer view of the initiative, refusing to spend any money for treatment vouchers in 2004.

"The committee has noted with interest the administration's Access to Recovery initiative to provide vouchers to states for substance-abuse treatment services," the Senate appropriations committee said in the report accompanying the Labor, HHS, and Education spending bill. "However, due to tight budget constraints the committee has not provided funding for the administration's initiative. In addition, the committee has concerns that many implementation issues have not been resolved, such as the role of professional assessment, certification requirements, and the administrative costs of setting up a voucher program for treatment."

The committee concluded by saying it is "supportive of the administration's desire to expand the pathways to treatment, but believes that more details need to be resolved before major resources are provided to a new program."

The House and Senate will now have to meet to work out the differences between the two funding measures.

SAMHSA Outlines Voucher Program

The Senate's comments, in particular, echo the concerns of addiction-treatment advocates, who worry that the voucher program could open up public funding to programs that don't meet current state certification and training standards, particularly faith-based programs.

In a pair of recent fact sheets on Access to Recovery, SAMHSA alludes to three guiding principles for the program, including consumer choice, results orientation, and increasing capacity. But while the SAMHSA document calls for linking provider payments to demonstration of treatment effectiveness and recovery, it is silent on the issue of certification.

States, SAMHSA says, will be responsible for establishing eligibility criteria for providers. But there is nothing prohibiting states from setting the eligibility criteria so low that programs that fall short of industry-standard training and staff education could still receive federal treatment funds.

Nonetheless, the SAMHSA fact sheets provide the first detailed peek at President's Bush's voucher plan. Citing vast unmet need for treatment, and stating that "recovery is real," SAMHSA said that treatment can cut drug use by half even among the toughest client populations, and reduces criminal activity by 80 percent.

"When tailored to the needs of the individual, addiction treatment is as effective as treatments for other illnesses, such as diabetes, hypertension, and asthma," the Bush administration states.

Major emphasis is placed on the fact that Access to Recovery would be a state-run program, with governors the conduit for funding. State governors would apply for voucher money through a competitive-grant process, and would be required to use Access to Recovery money to supplement, not supplant, current funding and existing programs -- particularly the addiction block grant.

"Governor's offices will be eligible to apply because governors are key to assuring a coordinated approach among various state departments that come into contact with people with addictive disorders: state drug and alcohol authorities, mental-health authorities, departments of education, child welfare, Medicaid, and criminal-justice agencies," according to SAMHSA.

"States will have considerable flexibility in designing their approach, and may target efforts to areas of greatest need, to areas with a high degree of readiness, or to specific populations, including adolescents," according to SAMHSA.

Grant applicants would have to provide SAMHSA with plans for screening, assessing, referring, and placing addicted individuals. Clients would need to be assessed wherever they present for treatment, and states would have to detail in their funding applications "how the provider base will be expanded and how a broad array of provider organizations will become eligible for voucher reimbursement."

An Access to Recovery workgroup within SAMHSA is currently drafting a Request for Applications (RFA) for the voucher program, looking at such issues as state standards, performance measurement, services cost ranges, and assessment and placement tools. The RFA would be released if Congress approves money for the program.

Rhetoric and Reality

SAMHSA's three principles for the Access to Recovery program starts with consumer choice. The agency notes that people with addictions can find many pathways to recovery, including physical, mental, emotional, and spiritual. "With a voucher, people in need of addiction treatment and recovery support will have the choice to select the programs and providers that will help them most. Increased choice protects individuals and encourages quality," according to SAMHSA.

SAMHSA also is proposing broad standards for measuring program effectiveness, including, but not limited to, abstinence from use of alcohol and other drugs. Other possible outcome measures would include involvement in the criminal-justice system, employment status, social supports, living situation, access to care, and retention in treatment. States would be required to develop a system for measuring these outcomes.

The Access to Recovery program also intends to increase overall treatment capacity by 100,000 clients annually and expand the variety of services available.

Officials and treatment providers in Milwaukee County, Wisc., have seen both the pros and cons of addiction-treatment vouchers since a local voucher program was established in the early 1990s. Paul Rodomski, director of adult community services at the Milwaukee County Behavioral Health Division, said the voucher system has succeeded in expanding the number of treatment choices available to clients. And Duncan Shrout, director of public policy and community programs for Impact Alcohol and Other Drug Abuse Services, Inc., says the program has increased competition and helped make programs more community-based.

But Rodomski said that if vouchers do increase quality and competition, it is not due to market forces but because treatment programs are trying to qualify to get into the county's provider network. In Milwaukee, he said, providers must not only be state-certified but also meet a slew of county criteria if they want to join the voucher program, including having certified staff and insurance coverage, submitting to annual audits, and complying with other requirements typical of a services contract. (One local faith-based provider applied for the network, met the criteria, and is now part of the county voucher system, Rodomski noted.)

"The competition is not in the client choosing where to go; the competition is in the provider trying to get into the network," said Rodomski. " I am setting up the competitive process. If they can't meet the standards, they're not in the system.

"You're not going to get quality by somebody getting a voucher and choosing one program over another," he said. "It may just be that one's on the main bus line and the other isn't."

Rodomski also cautioned that simply offering clients a choice is not enough: "Many clients are making choices, but they're not educated choices," he said. Intake services need to provide detailed descriptions of program modalities, specialties, and, as pertinent, religious orientation, said Rodomski.

Rodomski said some of the problems encountered in Milwaukee are not tied to the fundamental concept of vouchers. For example, he said, Milwaukee's "central" intake system has morphed into seven separate intake centers, which do not follow standardized assessment procedures -- a situation the county is currently trying to change.

"I think vouchers, if done right, are fine," said Rodomski. "But I have to have a lot of control over them. I have to limit the size of the network, make sure there are good providers, make sure they're delivering quality services, and have good information systems.

"Having vouchers that just let clients go wherever they want I would never support: I can't measure that," he said, adding: "I'm going to try to get a good mix of providers, but I'm also going to ensure that the accountability is there."