Bonnie L. Norton
Presidential Management Fellow
C. Stephen Redhead
Specialist in Health Policy
The Substance Abuse and Mental Health Services Administration (SAMHSA), within the Department of Health and Human Services (HHS), provides federal funding to support community-based mental health and substance abuse prevention and treatment services. SAMHSA awards formula and competitive grants under its authorities in Title V of the Public Health Service Act (PHSA). The agency also administers the $1.8 billion Substance Abuse Prevention and Treatment (SAPT) block grant and the $420 million Community Mental Health Services (CMHS) block grant, both of which are authorized in PHSA Title XIX. SAMHSA’s funding totaled almost $3.6 billion in FY2010. The agency’s budget increased by 34% from FY2000 to FY2010. In real (i.e., inflation-adjusted) dollars, however, the funding increase over that period was only 6%. Funding for SAMHSA’s two block grants, which together account for 62% of the agency’s budget, has grown at a much slower pace than funding for its competitive grant programs.
SAMHSA was reauthorized in 2000, as part of the Children’s Health Act (P.L. 106-310). The act amended SAMHSA’s existing authorities to give the agency more flexibility to direct mental health and substance abuse funding; increased state flexibility to direct the use of block grant funds, creating several new competitive grant programs to expand mental health and substance abuse services for children and adolescents; and authorized appropriations through FY2003. It also added charitable choice provisions that allow faith-based organizations to compete for SAMHSA substance abuse funding without impairing their religious character. P.L. 106-310 required SAMHSA to submit two reports to Congress, one on providing coordinated care to individuals with co-occurring mental illness and substance abuse, and the other on efforts to improve the flexibility and accountability of the block grants.
Comprehensive reauthorization has not occurred since 2000. However, several laws have further expanded the agency’s programs and activities in suicide prevention, underage drinking, and prescription drug abuse. The Patient Protection and Affordable Care Act of 2010 (P.L. 111-148) contained new authorizations for SAMHSA related to depression and behavioral health services for American Indians and Alaskan Natives, as well as additional provisions related to mental health and substance abuse.
While reauthorization has not moved out of committee, issues that may be of interest during the next reauthorization of SAMHSA include increased performance measurement and accountability for SAMHSA grants and programs, granting specific authority for the Access To Recovery program that provides vouchers for individuals to seek treatment services, improving the ability of communities to provide behavioral health services during disaster response, requiring collaboration between SAMHSA and other federal agencies, increasing SAMHSA’s level of emphasis on primary prevention, increasing SAMHSA’s role in expanding the number and diversity of the behavioral health provider workforce, and ensuring fairness of the formula used to distribute SAMHSA’s block grants.
This report describes SAMHSA’s history, organization, authority, and programs, and analyzes some of the issues that may be considered by Congress during a reauthorization of the agency. The appendixes include a table describing SAMHSA’s authorizations and appropriations, a table with SAMHSA’s funding from FY2000-FY2010, a matrix of SAMHSA’s National Outcome Measures that aim to evaluate progress on substance abuse and mental health prevention and treatment indicators, and a list of SAMHSA resources.
Date of Report: November 4, 2010
Number of Pages: 37
Order Number: R41477
Price: $29.95
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C. Stephen Redhead
Specialist in Health Policy
On March 23, 2010, President Obama signed into law a comprehensive health care reform bill, the Patient Protection and Affordable Care Act (PPACA; P.L. 111-148). The following week, on March 30, 2010, the President signed the Health Care and Education Reconciliation Act of 2010 (HCERA; P.L. 111-152), which amended various health care and revenue provisions in PPACA.
Among its many provisions, PPACA (as amended by HCERA) restructures the private health insurance market, sets minimum standards for health coverage, creates a mandate for most U.S. residents to obtain health insurance, and provides for the establishment by 2014 of insurance exchanges through which certain individuals and families will be able to receive federal subsidies to reduce the cost of purchasing that coverage. The new law expands eligibility for Medicaid; amends the Medicare program in ways that are intended to reduce the growth in Medicare spending that had been projected under preexisting law; imposes an excise tax on insurance plans found to have high premiums; and makes other changes to the tax code, Medicare, Medicaid, and numerous other federal programs.
In some instances, PPACA mandates appropriations or requires the Secretary to transfer from the Medicare Part A and Part B trust funds billions of dollars to support new or existing grant programs and other activities. This report summarizes those mandated appropriations and fund transfers. They include funding for a temporary insurance program for individuals who have been uninsured for several months and have a preexisting condition, as well as funding for states to plan and establish exchanges. PPACA also provides funding for various Medicare and Medicaid demonstration programs, for the creation of a Center for Medicare and Medicaid Innovation to test and implement innovative payment and service delivery models, and for an independent board to provide Congress with proposals for reducing Medicare cost growth and improving quality of care for Medicare beneficiaries.
Among other provisions, the new health reform law appropriates funding for health workforce and maternal and child health programs, and establishes three multi-billion dollar funds. The first fund will provide a total of $11 billion over five years in supplementary funding for community health centers and the National Health Service Corps. (A separate appropriation provides $1.5 billion for health center construction and renovation.) The second fund will support comparative effectiveness research through FY2019 with a mixture of appropriations and fund transfers. The third fund, which is funded in perpetuity, is to support prevention, wellness, and other public health-related programs and activities authorized under the Public Health Service Act (PHSA).
In addition to the mandated appropriations and fund transfers discussed in this report, PPACA authorizes new funding for numerous existing discretionary grant and other programs and activities, primarily ones authorized under the PHSA. It also creates a number of new discretionary grant programs and activities and provides for each an authorization of appropriations. Funding for all of these discretionary programs and activities is subject to action by congressional appropriators. A companion product, CRS Report R41390, Discretionary Funding in the Patient Protection and Affordable Care Act (PPACA), coordinated by C. Stephen Redhead, summarizes all the provisions in PPACA for which appropriations are authorized.
Date of Report: October 28, 2010
Number of Pages: 18
Order Number: R41301
Price: $29.95
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Nancy Lee Jones
Legislative Attorney
The Americans with Disabilities Act (ADA) has as its purpose providing “a clear and comprehensive national mandate for the elimination of discrimination against individuals with disabilities.” In order to effectuate this purpose, the ADA and its regulations require reasonable accommodation or modifications in policies, practices, or procedures when such modifications are necessary to render the goods, services, facilities, privileges, advantages, or accommodations accessible to individuals with disabilities. The reasonable accommodation or modification requirement has been interpreted to allow the use of service animals, even in places where animals are generally not permitted.
The Department of Justice (DOJ) has promulgated regulations containing specific details about service animals, and this report focuses on these regulatory requirements. Generally, a public entity (ADA title II) or a place of public accommodation (ADA title III) must modify its policies, practices, and procedures to allow an individual with a disability to use a service animal. The regulations also define service animals. A service animal is “any dog that is individually trained to do work or perform tasks for the benefit of an individual with a disability, including a physical, sensory, psychiatric, intellectual, or other mental disability.” (emphasis added). However, despite the regulatory limitation of the definition to dogs, miniature horses may be allowed in certain circumstances. A service animal does not need to be allowed when the animal is out of control or the animal is not housebroken. In addition, a public entity or place of public accommodation may not ask about the nature or extent of an individual’s disability but may ask two questions to determine if the animal is a service animal when it is not readily apparent. These questions are, if the animal is required because of a disability, and what work or task the animal is trained to do.
Several issues remain unresolved by the DOJ regulations. For example, the relationship between the ADA and Fair Housing Act in some situations is unclear. In addition, there is considerable ambiguity concerning how potentially conflicting claims for accommodations relating to service animals should be addressed.
Date of Report: October 28, 2010
Number of Pages: 9
Order Number: R41468
Price: $19.95
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C. Stephen Redhead, Coordinator
Specialist in Health Policy
Kirsten J. Colello
Specialist in Health and Aging Policy
Elayne J. Heisler
Analyst in Health Services
Sarah A. Lister
Specialist in Public Health and Epidemiology
Amanda K. Sarata
Specialist in Health Policy
The Patient Protection and Affordable Care Act (PPACA; P.L. 111-148), as amended by the Health Care and Education Reconciliation Act (HCERA; P.L. 111-152), authorizes new funding for numerous existing discretionary grant and other programs and activities. PPACA, as amended, also creates a number of new discretionary grant programs and activities and provides for each an authorization of appropriations. Funding for all of these programs and activities is subject to action by congressional appropriators. This report summarizes all the discretionary provisions in PPACA for which appropriations are authorized. A companion product, CRS Report R41301, Appropriations and Fund Transfers in the Patient Protection and Affordable Care Act (PPACA), summarizes all the mandated appropriations and Medicare trust fund transfers in the new law.
Among the provisions that are intended to strengthen the nation’s health care safety net and improve access to care, PPACA permanently reauthorizes the federal health centers program and the National Health Service Corps (NHSC). The NHSC provides scholarships and student loan repayments to individuals who agree to a period of service as a primary care provider in a federally designated Health Professional Shortage Area. In addition, the new law seeks to address concerns about the current size, specialty mix, and geographic distribution of the health care workforce. It reauthorizes and expands existing health workforce education and training programs under Titles VII and VIII of the Public Health Service Act (PHSA). Title VII supports the education and training of physicians, dentists, physician assistants, and public health workers through grants, scholarships, and loan repayment. PPACA creates several new programs to increase training experiences in primary care, in rural areas, and in community-based settings, and provides training opportunities to increase the supply of pediatric subspecialists and geriatricians. It also expands the nursing workforce development programs authorized under PHSA Title VIII to bolster undergraduate and graduate nursing education and training.
As part of a comprehensive framework for federal community-based (i.e., public health) prevention activities, including a national strategy and a national education and outreach campaign, PPACA authorizes several new grant programs with a focus on preventable or modifiable risk factors for disease (e.g., sedentary lifestyle, tobacco use). The new law also leverages a number of mechanisms to improve the quality of health care, including new requirements for quality measure development, collection, analysis, and public reporting; programs to develop and disseminate innovative strategies for improving the quality of health care delivery; and support for care coordination programs such as medical homes, patient navigators, and the co-location of primary health care and mental health services.
Additionally, PPACA authorizes funding for programs to prevent elder abuse, neglect, and exploitation; grants to expand trauma care services and improve regional coordination of emergency services; and demonstration projects to implement alternatives to current tort litigation for resolving medical malpractice claims, among other provisions.
The new law also reauthorizes the Indian Health Care Improvement Act (IHCIA), which sets out the national policy for Indian health care and authorizes programs and services provided by the Indian Health Service. For more information on PPACA’ s Indian health provisions, which are not discussed in this report, see CRS Report R41152, Indian Health Care Improvement Act Provisions in the Patient Protection and Affordable Care Act (PPACA).
Date of Report: October 14, 2010
Number of Pages: 33
Order Number: R41390
Price: $29.95
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Joe Richardson
Specialist in Social Policy
A comprehensive congressional review (“reauthorization”) of the primary laws governing child nutrition and WIC programs (the Richard B. Russell National School Lunch Act and the Child Nutrition Act) was scheduled for 2009 (the last reauthorization was in 2004). Congress did not meet the September 30, 2009, deadline for comprehensive reauthorization. Instead, a one-year extension (through September 30, 2010) was included in the FY2010 Agriculture Department appropriations measure to give Congress time to consider a full reauthorization bill. The delay in child nutrition/WIC reauthorization was primarily due to a lack of agreement on how to fund any new child nutrition initiatives subject to congressional “pay-go” rules. The Administration had proposed spending $10 billion over the next 10 years on expanding child nutrition efforts to “end childhood hunger by 2015,” but did not offer specific policy changes or spending/revenue offsets. In 2010, Congress moved to begin the process of enacting the most sweeping changes in child nutrition and WIC programs since the 1970s.
In May, the Senate Agriculture, Nutrition, and Forestry Committee reported the Healthy, Hunger- Free Kids Act of 2010 (S. 3307; S.Rept. 111-178). It made substantial changes in child nutrition and WIC programs (most importantly, increasing federal financing for school lunches) that are estimated to cost just under $5 billion over the next 10 years. It also included spending reductions in other programs that would offset this cost. Most significantly, it (1) reduced payments under the Agriculture Department’s Environmental Quality Incentive Program (EQIP) and (2) included a restructuring of, and long-term cut in spending for, the nutrition education component of the Supplemental Nutrition Assistance Program (SNAP, formerly the Food Stamp program). On August 5, 2010, the Senate approved an amended version of S. 3307. It differed from the Committee-reported version of the bill in that it replaced savings from the EQIP offset with spending reductions achieved by reducing future benefits under the Supplemental Nutrition Assistance Program (SNAP, formerly the Food Stamp program) and dropped authority for the Agriculture Department to bar certain foods from the WIC program.
In July 2010, the House Education and Labor Committee approved the Improving Nutrition for America’s Children Act (H.R. 5504, as extensively amended in committee). This bill included provisions that are much the same as the Senate initiative, but the anticipated cost is substantially larger because of provisions expanding child nutrition efforts beyond those in the Senate’s bill and only relatively minimal offsets.
The Senate and House bills have now placed an extensive menu of policy changes on the table, but how to pay for them is still the overriding issue; there is little disagreement over most of the policy changes themselves.
As in 2009, Congress has now missed its newest deadline for child nutrition/WIC reauthorization (September 30, 2010, set by the Agriculture Department appropriations FY2010 appropriations act). Instead, the FY2011 “continuing resolution” (P.L. 111-242) extends funding support for child nutrition and WIC programs (under current-law rules) until early December 2010.
Date of Report: October 12, 2010
Number of Pages: 23
Order Number: R41354
Price: $29.95
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