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{X The Evolution of Financing Policy
As treatment has advanced and become more specialized, there have been
significant changes in the financing and organization of treatment services. Financing the
treatment perhaps more accurately the custodial care-of persons with alcohol problems
was previously seen as primarily the responsibility of the states as part of their mental
health program. Until the early 1970s, the majority of individuals admitted for inpatient
treatment of alcohol problems went to state mental hospitals, fewer than 10 percent of
which had special wards or programs for such treatment. Indeed, in the 1960s, up to 40
percent of all the admissions to state hospitals were "chronic problem drinkers" (Glasscote
et al., 1967; Plaut, 1967~. There were few general hospitals that had special wards or
programs; those that did have such units provided primarily emergency care and
detoxification. Most private psychiatric hospitals also lacked separate programs; persons
with alcohol problems (who constituted approximately 6 percent of admissions) were treated
in their general psychiatric units (Glasscote et al., 1967~. By 1986, the situation had
changed dramatically: in a survey conducted by the American Hospital Association, there
were 1,097 hospitals reported offering treatment for alcohol problems in a specialized
program (1,039 general, psychiatric, and other specialty hospitals had designated units and
58 specialty hospitals offered "alcoholism/chemical dependency treatments) (AMA, 1987~.
The number of outpatient and nonhospital residential facilities and programs has
seen similar growth. There were only 130 outpatient clinics and 100 halfway houses and
recovery homes which specialized in providing care for alcohol problems when the original
survey was conducted in 1967 (Glasscote et al., 1967~. Many of the halfway houses
surveyed were privately funded clinics that provided safe withdrawal and supportive care for
the well-to-do; others had been started by AA members as Twelfth Step houses to provide
similar services on a voluntary basis. In contrast, in 1987, there were over 5,700 distinct
specialty programs that reported providing treatment for alcohol problems within an
identifiable unit (NIDA/NIAAA, 1989~. More than 2,000 were outpatient facilities, and
more than 1,300 were residential facilities (e.g., halfway houses, recovery homes).
Since the early 1970s and the first efforts to develop separate funding and
organizational structures for specialty, high-quality treatment for alcohol problems, the
mechanisms for funding such treatment have undergone a number of shifts. The first shift
was from state and local undifferentiated funding to state, local, and federal government
categorical grants and contracts. (Categorical grants and contracts are funds targeted to
meet a specific need of a specific population through an application process with tightly
defined program and administrative requirements.) Indeed, categorical government
appropriations became the major sources of funding for treatment of persons with alcohol
problems (Booz-Allen and Hamilton, Inc., 1978; USDHHS, 1981; Akins and Williams, 1982;
Cahalan, 1987; Butynski and Canova, 1988~. With this change came a different notion of
what treatment should be. Financing treatment for alcohol problems was formerly seen as
the responsibility of state and local governments; they were most likely to fund emergency
care for public inebriates in jails and in public hospital emergency rooms and custodial care
for chronic alcoholics in state mental hospitals. Together with the shift toward government
categorical funding of treatment came the concept of a shared federal-state responsibility
to develop a continuum of specialist treatment services in each community. The federal
government thus provided categorical grants for community-based services and encouraged
the states to increase their categorical funding of these programs (President's Commission
on Law Enforcement, 1967a,b; Boche, 1975; Weisman, 1988~.
The second important shift in funding that has occurred since the 1970s has been
the move toward increased coverage of specialized treatment for alcohol problems as a
406
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IlIE EVOLUTION OF FINANCING POLICY
407
separate, discrete benefit by public and private third-party payers. As a result, financing
treatment for alcohol problems is now accepted, albeit not without reservations, as also the
responsibility of the federal government (acting on behalf of the categorically needy, the
elderly, and the chronically disabled) and of private insurers (acting on behalf of employers
and individuals who purchase health insurance) (e.g., Leland et al., 1983; Sievert, 1983~.
As discussed in Chapter 8, initiating these shifts in funding sources and developing
a stable financing base have been major priorities of the voluntary associations and
governmental agencies involved in specialty treatment for alcohol problems. All of these
groups placed major emphasis on moving the financing of treatment for alcohol problems
into the mainstream of health care financing; their efforts have led to a substantial increase
in the total contribution of private health insurance, state and local categorical funds, and
self-payment. There is continuing involvement of the federal government as a source of
financing as well, but its relative contribution through both categorical funds and public
health insurance has diminished. One consequence of the lessening of the federal role has
been a substantial variability in sources and level of funding among the states and within
the public and private specialist sectors (Jacob, 1985; Institute for Health and Aging, 1986;
USDHHS, 1987).
Major questions are now being raised about whether current financing and
reimbursement policies provide for access to the most cost-effective treatments (Freeborn,
1988~. These policies have evolved over the last 20 years through a combination of
government initiatives, research findings, and advocacy efforts. Recently, they have come
into conflict with policies relating to cost containment and have been faced with questions
regarding the effectiveness of current strategies (Gordis, 1987; Holden, 1987; Wallace, 1987;
Gibson, 1988; Lewis, 1988~. It may be helpful to look briefly at some of the noteworthy
points along this evolutionary path for a historical perspective on the current state of
funding policy.
Development of a National Policy
The recommendations of the Joint Commission on Mental Illness and Health
(1961) are a good starting point for observing the development of a national policy on
funding of treatment for alcohol problems. These recommendations were the driving force
behind the shifts from state-dominated operation and financing of institutional services
toward an increasing role for, first, the federal government (through categorical grants for
community-based services) and, then, for public and private health insurance in financing
a continuum of community-based treatment services for all mental disorders, including
alcohol problems. Similar efforts of the Cooperative Commission on the Study of
Alcoholism were aimed at removing the financial barriers to treatment of problem drinkers
in community-based traditional hospital and nontraditional social model residential settings.
One of the commission's most far-reaching recommendations was that a national
organization be supported which would provide leadership in developing a coordinated
approach to research, prevention, manpower development, and treatment throughout the
United States (Plaut, 1967; Chafetz, 1976; Lewis, 1982; gurney, 1987~.
The major impetus for change in both the financing and organization of treatment
for all mental illness came in 1963, with the passage of the Mental Retardation Facilities
and Community Mental Health Centers Construction Act of 1963 (P.L. 88-164~. The
major impetus for similar change in treating alcohol problems came in 1970 with the
passage of the "Hughes Act," the Comprehensive Alcohol Abuse and Alcoholism
Prevention, Treatment, and Rehabilitation Act of 1970 (P.L. 91-616~. With this legislation
came establishment of the National Institute of Alcohol Abuse and Alcoholism as the focal
point for the coordination of federal activities and for the development of national policies
~. ~
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408 BROADENING THE BASE OF TREATMENT FOR ALCOHOL PROBLEMS
and priorities (USDHEW, 1971; USGAO, 1977; NIAAA, 1984; Cahalan, 1987; Lewis,
1988a).
Important contributions to a national policy were made by the Task Force on
Drunkenness of the President's Commission on Law Enforcement (1967b) and by a series
of court decisions that supported the disease concept of alcoholism (Hart, 1977; Lewis,
1982~. These efforts focused on the ineffective and inhumane handling of public inebriates
within the criminal justice system, recommending that such individuals be treated within a
public health model. The President's Commission on Law Enforcement (1967a)
recommended that a network of detoxification centers be established to replace local jail
facilities for public inebriates.
One important factor in bringing about the recommended changes was the efforts
of Senator Harold Hughes (as chair of the Special Subcommittee on Alcoholism and
Narcotics) Senator Harrison Williams, Congressman Paul Rogers, and a coalition of
constituent groups led by the National Council on Alcoholism and the North American
Association of Alcohol Problems. As a result of their efforts, the National Center for the
Prevention and Control of Alcoholism was established in 1969 within the NIMH Division
of Special Mental Health Programs. In 1970 the center was upgraded and renamed the
Division on Alcohol Abuse and Alcoholism to give added visibility to the federal effort.
. _ _ ,, _
The Establishment of the National Institute on Alcohol Abuse and Alcoholism
The advocates of the new "problem drinking approachn embodied in the reports of
the commissions noted above were not content with the establishment of the Division on
Alcohol Abuse and Alcoholism. They were pushing for an even more visible and
independent federal alcohol control agency which would not be dominated by the larger
mental health establishment (Lewis, 1982, 1988; Neiberding, 1983; Cahalan, 1987; Weisman,
1988~. Their goal was to redefine alcoholism as a primary illness rather than a symptom
of mental illness (its position at that time). Their strategy was to create a network of
specialist treatment facilities linked within a continuum of care (D. J. Anderson, 1981~.
With the early support of President Johnson and his assistant, Joseph Califano, who was
later to become secretary of health, education and welfare, Senator Hughes and the
constituent groups sought and ultimately received congressional authorization for a program
of direct federal funding of alcohol treatment and prevention programs. This authorization
was embodied in the Comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment,
and Rehabilitation Act of 1970.
This legislation, known as the Hughes Act (P.L. 91-616), established the National
Institute of Alcohol Abuse and Alcoholism (NIAAA) as an independent institute within
the National Institute of Mental Health (NIMH). NIAAA's mission was to administer the
new programs which were authorized by the Hughes Act as well as those already
established through amendments to the Community Mental Health Centers Act (P.L. 90-574
and P.L. 91-211~. The secretary of health, education, and welfare, acting through NIAAA,
was required to develop and conduct comprehensive health education, training, research,
and planning programs for the prevention and treatment of alcohol abuse and alcoholism.
Using Federal Grants to Increase Treatment Resources
The Hughes Act also established two major new programs with significance for the
development of alcohol treatment services. The first was a program of formula grants (i.e.,
allotments to states according to a formula involving population, per capita income, and
need). States were to use these grants for planning, establishing, and maintaining
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THE EVOLUTION OF FINANCING POLICY
409
prevention and treatment programs. The second program was a two pronged approach
comprising project grants to public agencies and nonprofit organizations and contracts with
public or private organizations or individuals.
The formula grant program required preparation of state plans outlining needs and
resources for alcoholism programs and containing a description of the activities for which
the federal funds were to be used. The initial plan submitted by a state was to identify a
single agency, the state alcoholism authority (SAA) to administer the plan. The plan was
required to contain assurances that federal funds would supplement, not replace, state and
other nonfederal funds that were already being spent to support alcoholism programs.
In 1971, only a few of the states had oversight agencies in place that were similar
to the proposed SAA (i.e., that could develop and monitor specialty programs for treatment
of alcohol problems). (More than 40 states had separate alcohol programs, but the
programs were primarily engaged in public education; only a few states operated a specialty
inpatient program or provided funds for community-based outpatient clinics.) Most alcohol
treatment services were provided by the state mental health authorities, either directly in
state hospitals or through grants and contracts to newly developing community-based
programs. The formula grant program provided the means for all of the states and
territories to develop a new specialty oversight agency, the SAA, or to strengthen an
. , _
existing agency; whichever proved to be the case, fine resulting agency would tnt;n Try
provide categorical funds for specialized treatment services and coordinate and monitor
funds expended by other state agencies. NTAAA also provided financial support for the
development of a national organization, the Council of State and Territorial Alcoholism
Authorities, to promote the exchange of programming and financing strategies; this
organization later merged with a similar group founded by directors of state drug abuse
agencies to become the National Association of State Alcohol and Drug Abuse Program
Directors (NASADAD). NASADAD has become the major vehicle by which the states
interact with the federal government on policies for federal financing of treatment for
alcohol problems (skins and Williams, 1982; Butynski et al., 1987; Butynski and Canova,
1988~.
The initial appropriation for the NIAAA formula grants program was made during
the federal government's fiscal year 1972 and represented 35 percent of the institute's
appropriation for all activities that year. By the end of the fiscal year, all of the states had
submitted their required plans and received formula grant awards. The formula grant
program ended in 1981. Approximately 80 percent of the formula grant expenditures over
the years were for intervention, treatment, and rehabilitation services.
The second new program authorized by the Hughes Act consisted of project grants
and contracts (awarded and administered by the secretary acting through NIAAA) to
conduct demonstration, service, and evaluation projects. The initial focus of the program
was on the use of project grants to demonstrate the feasibility of providing
community-based intervention and treatment that was oriented toward the integration of
services and the provision of comprehensive services. Through these projects, combined
with the education and training of personnel, and cooperation with other agencies, NIAAA
was to assume the leadership role in developing treatment capacity across the nation.
Indeed the new institute's highest priority was the expansion of available treatment for
persons with alcohol problems within their home communities (USDHEW, 1971~. The
major barriers to accomplishing this goal were the stigma attached to alcoholism, which was
still viewed as a moral failing rather than as a disease; general ignorance about the
condition; general hospital admission practices that excluded persons with alcohol problems;
and the exclusion of alcohol-related disorders from health insurance coverage.
The strategy DHEW and NIAAA adopted was to expand treatment resources as
rapidly as possible through categorical grants to states, local governments, and local
community groups for treatment and rehabilitation services. The primary target population
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410 BROADENING THE BASE OF TREATMENT FOR ALCOHOL PROBLEMS
for these initial categorical grant programs were uninsured persons with alcohol problems
(i.e., public inebriates, poverty area residents, and ethnic minorities). The initial
appropriation for the categorical grants program was made in federal fiscal year 1972. In
addition to the new grants for treatment services, staffing grants for comprehensive
community alcoholism programs had previously been awarded under amendments to the
Community Mental Health Centers Act. These grants were now also to be administered
by NIAAA Originally, these staffing grants utilized the initial community mental health
centers model, which called for five essential services organized within a continuum of care
to a delineated catchment or service area; the five services are: (1) inpatient care; (2)
outpatient care; (3) intermediate care such as halfway houses and day or night hospitals;
(4) emergency care; and (5) consultation and education services (see Chapter 3~. These
staffing grants were later redefined and became NIAAA's cross-population demonstration
program, keeping the concept of the continuum of care but eliminating the catchment area
concept and the concept of five essential services (Booz-Allen and Hamilton, Inc., 1978~.
In keeping with its mission as the central federal agency for alcohol-related
activities, other programs also moved under NTAAA's control. When the Office of
Economic Opportunity was abolished in 1972, NIAAA assumed the administration of
almost 200 grants serving residents of low income areas, American Indians, and Alaskan
natives. These projects were originally funded under the Economic Opportunity
Amendments of 1968 and 1969 and were the first federal grants for services to persons with
alcohol problems; they provided primarily outreach and linking services or outpatient care,
or both. The largest group of grantee agencies funded under this program comprised
community action agencies, whose activities focused on social advocacy and linking poor
persons with alcohol problems to treatment providers. The poverty grant program became
the largest of NIAAA's special population categorical program areas, constituting
approximately 54 percent of all such grants. Problems were encountered when the transfer
occurred because the program's social advocacy and social services approach was not
consistent with the field's effort to integrate treatment of person's with alcohol problems
into more traditional health care financing mechanisms. These poverty grantees were seen
as the group least likely to continue to receive funding if categorical grants were
discontinued because their approach was not consistent with the treatment approach favored
by state or third-party funders (Booz-Allen and Hamilton, Inc., 1978~.
During the lifetime of this categorical project grant mechanism, grants for treatment
and rehabilitation services to special, or underserved, populations received priority as a
way to complement the Generic treatment provided through the community mental health
services approach (comprehensive services to a designated catchment area) (USDHEW
1971; see section IV). In addition to the cross-population, poverty, and Indian grants,
additional programs were created to fund demonstrations of effective services for Hispanics,
blacks, women, youth, the elderly, drinking drivers, criminal justice clients, gays and
lesbians, migrant farmworkers, physically handicapped persons, and public inebriates.
NIAAA prepared guidelines for grant applications to identify those elements that were
thought to be essential components of treatment services for each of the special populations
(e.g., child care services to enable women to enter inpatient residential treatment;
vocational counseling and job training for low-income ethnic minorities; outpatient
counseling for youth).
A third treatment oriented grant program was established in 1974. The incentive
or uniform act grant program was designed to provide additional financial support for
treatment services to those states that decriminalized public intoxication and provided
treatment rather than jails for intoxicated persons (Grad et al., 1971; USD HE W. 1971;
Finn, 1985; gurney, 1987~. As an additional encouragement to this trend of treatment
rather than jail, NIAAA supported the development of the Uniform Alcoholism and
Intoxication Treatment Act by the National Conference of Commissioners on Uniform State
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THE EVOLUTION OF FINANCING POLICY
411
Laws (see Chapter 3 and Appendix D). When the NIAAA program ended in 1981, 34
states had passed an acceptable version of the Uniform Act and received incentive grants
(Finn, 1985~.
Despite NIAAA's effort to strengthen the SAAs through the formula and incentive
grant programs, the early years of the NIAAA categorical grant program were marked by
a lack of communication and coordination about funding priorities with the SAAs
(USGAO, 1977; Booz-Allen and Hamilton, Inc., 1978~. To improve cooperation, the states
and NIAAA collaborated in the development of a demonstration program, in which the
SAA would become the grantee for all project grants, assume responsibility for monitoring
the adequacy of treatment, and provide data on accomplishments (skins and Williams,
1982~. While this project grant mechanism was still in the demonstration phase, however,
the alcohol, drug abuse, and mental health services block grant was established by statute.
The block grant consolidated the project and formula grant and contract programs
administered by NIAAA and transferred responsibility for administration of these services
funds to the Alcohol, Drug Abuse, and Mental Health Administration (ADAMHA). The
leadership role in treatment capacity and services development was transferred to each of
the states in keeping with the intent of the legislation to allow states the flexibility to set
and carry out their own priorities (ADAMHA, 1984~. There was also a cutback in the
level of federal funds (Sharfstein, 1982; Robertson, 1988~. The determination of the level
and form of treatment services and their financing is fairly well left to each state. The
block grant mechanism is still in place today, and states now allocate block grant funds
according to the same policies by which they allocate state appropriations (USGAO, 1984;
ADAMHA, 1988~.
Efforts to Increase Public and Private Health Insurance
A second major emphasis in early NIAAA activities was on demonstrating that
treatment of the employed individual who was experiencing alcohol problems was beneficial
to both the individual and the employer; the primary mechanisms for these efforts were
grants for the establishment of occupational alcoholism programs (now known as employee
assistance programs) and the creation of an alcoholism counseling service for federal
employees (Trice, 1986; Roman, 1988~. In addition, NIAAA offered grants to each SAA
to develop its own statewide program of consultation and technical assistance to local
businesses and government agencies that were considering the establishment of occupational
alcoholism programs. In particular, the state consultation programs highlighted the cost
savings to be achieved through the adoption of company policies for identifying, referring,
and treating the employee with alcohol problems in concert with the adoption of a specific
health insurance benefit that encouraged early intervention for employees whose job
performance was impaired by alcohol problems. A significant part of NIAAA's effort in
this area was support for research on the development and testing of model health
insurance benefit packages (e.g., Berman and Klein, 1977a, Hallan and Holder, 1983; Holder
and Those, 1986~.
Working with the major voluntary association, the National Council on Alcoholism
(NCA), and representatives from the insurance industry, NIAAA sponsored the
development and dissemination of a model benefit package in 1973 (USDHEW, 1974;
Williams, 1981~. The suggested benefit structure was developed through a review of the
existing coverage of treatment services for alcoholism and alcohol-related conditions offered
by both private insurers and public insurers (Medicare and Medicaid) and by analyzing the
costs and practice patterns of current NIAAA grantees (USDHEW, 1974~. NIAAA offered
the model benefit plan to insurers and companies purchasing health insurance as a basis
for projecting a reasonable range of possible costs to use in their negotiations. The model
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412 BROADENING THE BASE OF TREATMENT FOR ALCOHOL PROBLEMS
was also seen as a guide for future studies of the impact of providing coverage on the cost
of insurance coverage.
The cost estimates in the model were derived from analyses of 27 treatment
programs offering treatment in more than 60 settings. The model was designed to reflect
the continuum of care with a projected length of stay for each setting required for
treatment: inpatient emergency cared days; inpatient care-14 days; intermediate care, short
term 30 days; intermediate care, long term 6()-90 days; and outpatient care-30 visits. When
it distributed the package, NIAAA noted that costs varied significantly among the variety
of settings in which equivalent care or treatment was provided (e.g., general hospital
-
inpatient emergency care was tound to cost trom ~ tO 1U umes as mucn as olner em`;rg`;ncy
care settings), a factor that continues to require consideration today (Holder and Hallan,
1983; Holder et al., 1988) (see Chapter 8~.
This original benefit design attempted to incorporate then current expert opinion
on effective treatment regimens and to promote alternatives to inpatient hospital treatment,
including treatment in residential or partial care settings. NIAAA continued to encourage
the development and adoption of model benefit packages working with the voluntary sector,
professional associations, and state agencies; its role shifted in the late 1970s from
advocating a specific model benefit to sponsoring research and providing information on
which employers, third party payers, and other policymakers can base decisions on the
extent and nature of coverage (Luckey, 1987; USDDHS, 1987~. In recent years, however,
the leadership role in encouraging the adoption of a model benefit has been shifted to the
SAAB, which are working with the voluntary and professional interest groups in the field
to obtain voluntary expansions of benefits or to have such coverage mandated by law
(Alcohol and Drug Problems Association Task Force on treatment Financing, LYNX;
Butynski, 1986; Oregon State Health Planning and Development Agency, 1986;
Massachusetts Special Commission, 1988; New Jersey Department of Insurance, 1988~.
During the 1970s, the federal role in financing treatment for alcohol problems-as
with other physical and mental illnesses-was developmental: using the categorical grant
mechanism, federal efforts were directed toward capacity building and resource development,
embodied in such activities as basic and clinical research, professional training, and services
demonstration. In general, this support was seen as a temporary measure, to be used only
until the "more conventional" third-party financing mechanisms (particularly the expected
national health insurance) could be brought into play. This view was expressed in a report
by a study committee organized by the American Hospital Association (Advisory Panel on
Financing Mental Health Care, 1973:59~:
~- ~ ^0~
Personal services for alcohol abuse should be financed through the same
mechanisms as treatment for all other illnesses, even though some
categorical support for direct services may be necessary in initial states of
program development. The establishment of categorical administrative
structures and funding structures at the Federal level, while providing a
justifiable and necessary focus for the development of resources and the
coordination of existing ones, should represent a temporary mode of
approach. Fragmentation of authority and financing mechanisms within the
mental health field, unquestionably has contributed to increased costs and
reduced effectiveness. In the long run, federal programmatic support for
the control of alcohol abuse should not be separated from Federal funding
for all mental health programs.
Thus it was assumed that conventional third-party reimbursers (public insurance for
the indigent and private insurance for the employed and their families) would begin to
support these federally initiated alcohol treatment projects. Grantees were encouraged to
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THE EVOLUTION OF FINANCING POLICY
413
seek out funding from a variety of third-party payers, ranging from private health insurance,
to Medicaid, to Title XX Social Services funds (Morrison, 1978~. The Health Services
Funding Regulations and Guidelines [42 CFR. Sec. 50.101-1071 adopted in 1974 specified
~ · ~ · · · . · , · · ~ · , _ _ or_ _ ~
the steps to be taken to capture these funds. In addition, technical assistance was offered
to grantees through workshops, consultants, and manuals (Boche, 1975; Morrison, 1978~.
The goal was for projects to become financially self-sufficient, replacing federal categorical
grant funds with other third-party sources by the end of the demonstration period.
However, concerns began to surface about whether such a goal was realistic, and several
studies suggested that many NIAAA-funded categorical projects could not expect to capture
third party funds and to survive in the existing funding environment without significant
changes to meet the medical model requirements of third-party payers (Boche, 1975;
Booz-Allen and Hamilton, Inc., 1978; President's Commission on Mental Health Task Panel
on Alcohol-Related Problems, 1978; Creative Socio-Medics Corporation, 1981~.
Contemporary NIAAA reports sound the same theme as the American Hospital
Association committee report while continuing to seek separate alcohol-specific third-party
financing mechanisms. One of the agency's major objectives was to promote changes in the
practices of health insurers who were seen to discriminate against persons with alcohol
problems. This theme is consistently presented in each of NIAAA's early reports to
Congress, which also detail the agency's efforts to demonstrate that effective treatment of
alcohol problems is possible, that direct treatment of alcohol problems reduces other health
care and productivity costs, and that treatment for alcohol problems can be brought into
the "mainstreams-that is, included in existing health and social care systems (USDHEW,
1971; USDHEW, 1974; Chafetz, 1976; USDHHS, 1986~. Despite NIAAA's advocacy,
however, there were questions raised as to whether such mainstreaming was possible given
the nature of the services needed (supportive social as well as medical services) and the
continuing doubts of insurers and policymakers regarding the effectiveness of treatment
(Boche, 1975; Booz-Allen and Hamilton, Inc., 1978; Leyland et al., 1983; Saxe et al., 1983;
Sievert, 1983; Hurst, 1987~.
To aid the survival of its grantees and to further demonstrate the validity of its
approach, NIAAA funded a variety of projects aimed at addressing the concerns of
Congress, the states, and the insurance industry regarding quality of treatment delivered,
the effectiveness of treatment, and the costs of adding treatment of alcohol problems as a
covered benefit. For example, NIAAA awarded a contract to the Blue Cross/Blue Shield
Association to study the feasibility of offering a comprehensive benefit that would include
the new nontraditional settings for treatment as eligible providers, allow counselors as well
as physicians, psychologists, and social workers to be included in coverage, and provide
coverage for the newer psychosocial modalities (e.g., family treatment) (Berman and Klein,
1977a). Another contract supported the development of accreditation standards for
alcoholism treatment facilities by the Joint Commission on the Accreditation of Hospitals
(now the Joint Commission on the Accreditation of Health Care Organizations). Such
standards could be used to demonstrate that providers of treatment for alcohol problems
could meet the traditional quality control measures used by the insurance industry in
defining provider eligibility (Joint Commission on the Accreditation of Hospitals, 1979,
1983~. In addition, a combined management information and treatment evaluation system
was developed and its use made a requirement for NIAAA funding; these data were
. , _
considered by peer review committees in determining whether to continue NIAAA funding
of individual projects. Another NIAAA project was aimed at credentialing personnel; here,
the agency chose to develop model standards to be used by the states and voluntary
organizations in licensing or accrediting counselors (Birch and Davis Associates, Inc., 1984~.
While NIAAA was pursuing these avenues, state alcoholism authorities were
encouraging the nontraditional agencies they funded to attempt to bring in a mix of
patients and funding sources by conducting outreach to employers and by obtaining
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414 BROADENING THE BASE OF TREATMENT FOR ALCOHOL PROBLEMS
accreditation from the Joint Commission on Accreditation of Hospitals. A number of
states also strengthened their own licensing requirements. Their efforts brought some
progress. Insurers began to recognize state licensure of certain nonhospital programs as
a substitute for accreditation (Leyland et al., 1983~. However, efforts to obtain similar
recognition by Medicare and Medicaid were unsuccessful (Noble et al., 1978; Saxe et al.,
1983; Lawrence Johnson and Associates, Inc., 1983, 1986~.
The Current Situation
The Shifting Leadership Role
In 1982 the alcohol, drug abuse, and mental health services block grant established
by the 1981 Omnibus Budget Reconciliation Act (P.L. 97-35) replaced the NIAAA formula,
incentive, and project services grant programs. The action was taken as a result of general
congressional and administration concerns about the proliferation of categorical programs
that served many of the same client populations and the often duplicative and burdensome
federal reporting requirements (Agranoff and Robins, 1982; USGAO, 1982; Grupenhof,
1983~. Still in place today, the block grant is administered by the Alcohol, Drug Abuse,
and Mental Health Administration (ADAMHA), the umbrella agency established in 1974
to oversee NIMH, NIAAA, and NIDA; the grant provides funds to the states for
redistribution to local governments or agencies to carry out the general aims of the
legislation but with minimal federally directed requirements. The initial award was based
on the amount of funds which a state was receiving under the NIAAA categorical grant
programs, less 25 percent. Since the initial award, however, there have been several
adjustments in the level of the funding and in the formula because of concerns about
inequities in the distribution of funds among the states (W. J. Anderson, 1984; USGAO,
1985, 1987b; Institute for Health and Aging, 1987~.
The block grant was designed to be more flexible than NIAAA's categorical and
formula grants program in its application, administration, and reporting requirements.
There are relatively few restrictions placed on any of the block grants, although in some
cases monies have been "set asides for specific purposes (ADAMHA, 1984, 1988; USGAO,
1987a). The alcohol, drug abuse and mental health services block grant provides set asides
for primary prevention and increased treatment availability for women (NCA, 1987~. There
is also a restriction on the amount of the block grant that can be used to support state
administrative costs and a prohibition against using block grant funds to pay for hospital
treatment of alcohol and drug problems.
With the shift to block grant funding for treatment services, the leadership
previously exercised by NIAAA in the development of the network of specialist programs
and enhanced financing for treatment devolved upon the states (Lewis, 1982, 1988; Cahalan,
1987~. NLAAA's role has become primarily to fund and conduct research; to disseminate
research findings to improve the prevention and treatment of alcohol-related problems;
and to provide technical assistance in the development of effective alcohol abuse prevention
and treatment programs and activities (USDHHS, 1986; Butynski and Canova, 1988;
NASADAD, 1988~. The momentum for continued resource development and capacity
building has been shifted to the states and local communities, to advocacy groups, and to
professional associations.
OCR for page 415
THE EVOLUTION OF FINANCING POLICY
State and Local Government Activities
415
Today, each state has an identifiable unit charged with overseeing the development,
funding, and regulating of specialist treatment for alcohol problems and of monitoring the
quality of such treatment (USDHHS, 1986; NASADAD, 1988~. As noted earlier in this
chapter, the concept of a state alcoholism authority with specific functions was introduced
as part of the requirements to obtain federal formula grants under the Hughes Act; these
requirements were reduced with the passage of the block grant. Yet the SAAs have
remained in place, carrying out most of the same functions and continuing to provide
funding for treatment of low-income persons and other special populations.
The organizational placement, statutory structure, and functioning of the SAAs vary
from state to state (NASADAD, 1988~. In some states the SAA is part of an independent
agency that also serves as the single state authority for drug abuse (e.g., Connecticut); in
others it may be a component of a state mental health agency (e.g., Virginia, Alabama,
Illinois), of a health department (e.g., Ohio, Pennsylvania), or of a human resources
superagency (e.g., California, Minnesota). In fiscal year 1986, there were 14 states in which
the state health agency served as the SAA to receive the alcohol portion of the federal
block grant; all but one of these agencies were also the designated recipients of the drug
abuse portion of the block grant. In only 6 states were the state alcoholism, state drug
abuse, and state mental health authorities placed within the public health department
(Public Health Foundation, 1988~.
Funding practices and program administration vary considerably among the states
and territories (Butler and Littleffeld, 1985~. Although each state and territory has an
agency designated as responsible for funding and monitoring alcohol problem treatment
activities, this agency may not be the only state entity to expend such funds. In three
states (the District of Columbia, Indiana, and Montana), other state agencies are reported
to provide more funding to publicly supported specialty programs than does the SAA
(Butynski et al., 1987~. As discussed in Chapter 8, funding varies among the states in
terms of per capita levels and the relative proportion of funds available from state and
local government appropriations as well as from public and private health insurance. The
determinants of this variation are not clear. Additional empirical studies of the complex
funding environments that exist are required to understand the sources of variation.
The SAA usually provides categorical funds to specialty providers but generally
does not directly manage other funds for treatment in hospitals, correctional facilities, and
social services agencies. Some states contract directly with provider agencies (e.g.,
Colorado, Connecticut, Missouri); other states provide funds to counties or regional
coordinating agencies to use for provider contracting (e.g., Michigan, New York, California,
Pennsylvania, Virginia). In addition, some states that contract with counties also have
programs for contracting directly with providers on demonstration and other special
projects (e.g., New York, California).
Most state governments are the largest single purchaser in their state of treatment
services for alcohol problems through the categorical programs administered by the SAA
The NDATUS and SADAP survey data reported in Chapter 8 suggest that states provide
more than 50 percent of the funds available to nonprofit specialty programs, which
primarily serve the indigent and uninsured. The continuum of care supported by the
benefit package in each state program differs from that of other states; within states,
benefit plans of the Medicaid agency, the state employee health insurance program, and the
SAA programs also differ. For example, Medicaid continues primarily to support a medical
model of hospital-based detoxification and rehabilitation, whereas the SAA more often
supports a mixed medical and social model that also includes social services, relapse
prevention, and extended care in nontraditional, nonhospital settings (Lawrence Johnson
and Associates, Inc., 1986; Butynski and Canova, 1988~. Both public- and private-sector
OCR for page 416
416 BROADENING THE BASE OF TREATMENT FOR ALCOHOL PROBLEMS
programs reflect the dominance of the Minnesota model discussed in Chapter 3 (inpatient
primary rehabilitation followed by extended care or aftercare of decreasing intensity and
frequency and using a blend of AA and professional services).
The trends toward decentralization in funding decisions that were noted in the last
comprehensive study of the sources of and barriers to financing of treatment for persons
with alcohol problems have continued (Booz-Allen and Hamilton, Inc., 1978~; consequently,
the current environment is extremely complex, with large interstate and intrastate variation
in both funding levels and funding policies (Weisner and Room, 1984; Weisner, 1986~. The
role of substate units (e.g., counties, regional coordinating agencies) has continued to grow
in importance as more states require local matching funds as a condition of receiving
state-appropriated funds or federal "pass-through" monies (i.e., block grant or Medicaid
funds). This shift is reflected in the SADAP annual reports of state alcohol and drug
abuse agencies: there are six states in which the county or other local government share is
20 percent or more of the total expenditures for treatment of alcohol problems (Butynski
et al., 1987~.
Another factor in the development of coverage and reimbursement policies is the
trend toward combined alcohol and drug treatment programs and state and county
authorities. Reflecting both a desire for administrative simplicity and the perception that
more and more of the persons being seen in treatment have problems related to both
alcohol and other drugs, all but four of the states now have combined alcohol and drug
abuse state agencies (NASADAD, 1988~. Some states with combined agencies still have
separate funding mechanisms and policies for alcohol problems treatment (e.g., California,
Colorado, New York); others have the same mechanisms (an addictions, chemical
dependency, or substance abuse orientation as in Connecticut, Minnesota, and Michigan).
Still others administer their funds for treatment of alcohol problem as part of a combined
alcohol, drug, and mental health funding mechanism (e.g., Virginia's Community Services
Boards; Alabama's integrated community services).
The diversity in funding policies and organization that exists among the states can
be best communicated by describing several of the current state programs. California
represents the administrative combination of distinct drug and alcohol programs into a
single department within a large human resources agency. The California SAA has adopted
a social model in its funding of specialist treatment for alcohol problems. Minnesota and
Oregon represent combined alcohol and drug programs which have adopted mixed medical
and social model concepts and administrative requirements. The three SAAs are
attempting to deal with the issues of improving provider accountability and increasing the
availability of appropriate treatment using different mechanisms.
Californuz The California SAA, the Alcohol Program Division within the
Department of Alcohol and Drug Programs, represents an increasingly common
administrative pattern (California Department of Alcohol and Drug Programs, 1988~. The
California SAA has an annual budget of approximately $64 million for treatment. Funds
are primarily distributed through county agencies that serve as county alcohol authorities
_
and purchase specific services from local providers. The state's Alcohol Program Division
assists counties in the planning, development, implementation, coordination, and funding
of local prevention, treatment, and rehabilitation programs. The state agency identifies
statewide objectives and priorities that serve as guidelines to the counties in the
preparation of their county alcohol plans. The county plans are then used as the basis for
receiving state funding.
The continuum of services for treatment of persons with alcohol problems
administered by the California State Department of Alcohol and Drug Programs includes
three categories of residential programs (detoxification, short term and extended-term
residential treatment, and short term and extended-term recovery homes) and three
categories of nonresidential services (treatment/recovery, vocational rehabilitation, and
OCR for page 444
444 BROADENING THE BASE OF TREATMENT FOR ALCOHOL PROBLEMS
appropriate level of care (settirlg) and the appropriate treatment orier~on, and midday for an
individual at each stage of Comment. Bringing together researchers, practitioners, funders,
and regulators in an expert committee for a systematic review of the various methods
currently in use and of the experiences of both payers and providers in applying those
methods could lead to the adoption of a common framework and a reduction in the
confusing array of criteria systems that now confronts purchasers and providers of services
alike. Although additional research is required on the effectiveness of specific treatment
matches, the committee believes that there is now sufficient data and experience for the
development of a common framework. What has been lacking is a neutral and ongoing
forum for such an endeavor. The consensus activity the committee recommends could
provide such a forum and could continue on a regular basis (perhaps in the form of an
expert committee, as described in Chapter 11) offering an opportunity for researchers,
payers, and providers to review and consider matching approaches based on the results of
outcome monitoring activities and experimental studies. Such an endeavor could also
clarify the conditions under which the medical model and the social model are most
appropriate for use.
In addition to a surveillance program, there should be expanded support of health services
research programs that are current' investigating f Lancing policy issues. There are a renumber of
such programs that are funded at a minimal level, with appropriate m~difeations these research
programs could provide the necessary data for planners arid polipymakers to use in making
decisions regarding the allocation of resources and choices among competing modalities and
settings. The following research is needed: studies on the impact of the structure of
insurance benefits and of alternate cost-containment strategies on the availability and
outcome of treatment for alcohol problems; in-depth studies of the differences among
payers in policies and experiences in funding treatment of alcohol problems; in-depth
investigations of the variation among the states in the sources of funding available to
different types of providers; research on the impact of the availability of insurance benefits
on the level of treatment utilization in distinct populations; and effectiveness studies that
routinely include the mode of payment and cost data in their data collection and analyses.
Currently, the research funded by the federal government on the financing of
treatment for alcohol problems is minimal. NIAAA's (1988) recently issued program
announcement soliciting investigator-initiated research on economic and socioeconomic
issues in prevention, treatment, and epidemiology is a step in the right direction, but as
currently structured the program is too small to stimulate sufficient attention and produce
the volume of data that is needed. The committee strongly endorses the establishment of
visibility and priority for research on financing policy in the appropriate federal agencies.
The committee also recommends that NIAAA take the lead in these efforts, just as it has
led in the establishment and evolution of financing policy in previous years. Now,
however, the agency is positioned to play a key role in the refinement of that policy by
sponsoring more rigorous research and a broader program of studies to capture the data
required for sound decision making.
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Representative terms from entire chapter:
health insurance
