budget process and the grant review process. It is important to understand the budget process because it governs the activities of all federal agencies, by circumscribing the financial constraints under which they operate from year to year. The review process is equally important to understand because it influences the scientific identity of the institutes by determining which specific research projects get funded.
As outlined in Box 5.1, the organization of ADAMHA (and its predecessors) has always been problematic (IOM, 1991b). This is largely because, unlike the rest of the Public Health Service, ADAMHA included research, service, public health, and training activities all in one agency. The debate about the advantages and disadvantages of various options for administering all of these components continued (with periods of greater and lesser intensity) until Congress passed the ADAMHA Reorganization Act in 1992, which for the first time separated services and research into different agencies. On October 1, 1992, NIAAA, NIDA, and NIMH were moved organizationally to NIH, and a new agency—the Substance Abuse and Mental Health Services Administration (SAMHSA)—was created to manage the former ADAMHA service functions.
According to individuals both inside and outside of the Department of Health and Human Services (HHS), a number of complex reasons explain why the separation of research and services occurred successfully in 1992 and not earlier. First, the number of new programs and the budgets for these programs (especially those related to substance abuse) increased rapidly during the later part of the 1980s. As the agency grew, it had a more difficult time balancing the competing and sometimes conflicting missions of research and services (including the conflicting demands of constituency groups). Although internally the agency increasingly focused on research (by the late 1980s, the ADAMHA administrator and the directors of all three institutes were research scientists), the external community and HHS were more concerned about service and prevention activities. Under Bernadine Healy, NIH, which previously had fought against incorporating ADAMHA's research institutes, changed its position and actively sought the transfer of NIAAA, NIDA, and NIMH to NIH. The Office of National Drug Control Policy (ONDCP) in the White House also strongly favored the reorganization and believed that the research