By Andrew Kessler, Federal Policy Liaison
The economic situation faced by the nation is, in a word, dire. All programs dependent on the federal budget, regardless of endeavor, face drastic cuts in funding. Labor, education, transportation, agriculture, and even defense programs are, for the first time in decades, all in the same boat. Substance abuse programs are, not surprisingly, no exception. While these programs are a miniscule fraction of the federal budget, they are inexorably linked to larger federal fiscal policy, just as every other field that relies on federal funding is.
The Republicans, now in the majority in the House of Representatives, in large part ran on a platform of smaller government and spending cuts. While a large percentage of their candidates would not specify exactly what programs should be cut, this still does not bode well for health – and behavioral health – programs. The appropriations bill that funds the Department of Health and Human Services – and in turn SAMHSA and the NIH – is the largest non-military domestic spending bill to come out of congress each year. It is produced by the Appropriations subcommittee on Labor, HHS, and Education, or “Labor/H” for short. Being one of the largest spending bills, it naturally has a huge bulls-eye on it.
The House Republican Study Committee introduced a bill in January that would cut federal spending by $2.5 trillion over the next decade. The measure would hold FY 2011 non-security discretionary spending to FY 2008 levels, saving a total of $80 billion over 10 years. In the following fiscal years, the legislation would hold non-defense discretionary spending to FY 2006 levels, a move that would save $2.29 trillion through 2021. However, the Democrats, still in control in the Senate, are not likely to go along with such recommendations.
The House Rules Committee in January also passed a resolution (H Res 38) directing Budget Chairman Ryan to set a discretionary spending cap for the rest of fiscal 2011 that “assumes non-security spending at fiscal year 2008 levels or less.” This was the goal of the Sessions-McCaskill amendment, introduced in 2010, and defeated by the Senate. This is mostly a symbolic move, since Chairman Ryan already has the authority to set the discretionary cap for FY 2011 after the House rules passed earlier this month. This would be a cut in federal spending of 21%, or, in layman’s terms, the largest in modern history. This is not only an incredibly drastic cut, but also would be an incredibly complex one, as FY 2011 is already several months old. To this point, the federal government has been paying for FY 2011 by operating under a continuing resolution at FY 2010 levels. The current resolution extends until March 4. So to meet these cuts, federal programs would need to suffer drastic cuts over the next 5 months in order to bring spending down, which would be an accounting nightmare, and force those dependent on federal funding to juggle their respective budgets for the remainder of the year.
Returning to 2008 spending levels could result in significant cuts to programs administered by the Substance Abuse and Mental Health Services Administration, including: a $62 million reduction in Center for Mental Health Services Programs of National and Regional Significance; a $20 million reduction to the Substance Abuse Prevention and Treatment Block Grant; a $53 million reduction to the Center for Substance Abuse Treatment Programs of National and Regional Significance; and a $7 million reduction to the Center for Substance Abuse Prevention Programs of National and Regional Significance.
Substance abuse programs are already being slashed in the states, and many wonder what the impact of federal budget cuts will be. One-third of all funding in the states, for all government programs, comes in the form of block grants from the federal government. So a 21% cut for the federal government would have a severe impact on state spending as well, whether we’re talking about block grants from SAMHSA or from other federal agencies. On average, 40% of all states funding for addiction services come in the form of the SAMHSA block grant. For prevention services, SAMHSA block grants make up 64% of the states’ substance abuse prevention budget, and six states rely on block grants for 100% of their prevention budgets. So as the federal government budget suffers, the states will feel it on a colossal level.
Those of us who advocate for federal programs that help advance substance abuse prevention and treatment are going to have to “swim upstream,” so to speak. Our advocacy efforts, if focused solely on substance abuse prevention and treatment programs, will not be enough. A focus on the bigger picture is called for. Beyond SAMHSA, NIDA, and NIAAA within HHS, beyond programs for drug courts and juvenile justice in the Department of Justice, beyond programs for Indian Health in the Department of the Interior, we must fight to assure that spending for all federal programs is cut as little as possible.
If we wait until the budget process gets “downstream” to our specific programs of interest, the ship will already have sailed. Caps may already be in place, priorities will already have been determined. Whether we do this in coalitions, as individuals, or as part of a grassroots effort, it must be done. A focus on appropriations subcommittees can only come after a determined effort that centers on the appropriations committee as a whole, as well as the budget committees in the House and Senate.
In his State of the Union Address on January 25, President Obama proposed a five-year freeze on all domestic spending. This does not automatically mean that all programs concerning substance abuse prevention and treatment will be frozen or cut, as drastic cuts could take place in some government programs while others see increases. However, we should be pragmatic. The priorities for the nation right now, in the eyes of our leaders, are economic development, job creation, and the regulation of banks and investments in order to prevent another economic collapse. While a drug-free populace is a healthier one and indeed does have economic benefits, it is indeed a long shot to hold out hope that agencies such as SAMHSA and NIH will see increases over the next two to five years.
The House Appropriations Committee, responsible for establishing funding levels for every federal program, will be chaired by Hal Rogers of Kentucky. While Mr. Rogers does not have an impressive record of supporting Labor/HHS programs in the past, he is a dedicated founder of the newly established House Caucus on Prescription Drug Abuse. Mr. Rogers has been a strong voice for establishing policies that can cut prescription drug abuse and illegal trafficking. However, most of his work thus far has focused on law enforcement and their involvement in this issue. It remains to be seen if this zeal carries over to funding research and services that are connected to this issue. The subcommittee responsible for appropriations to the Department of Health and Human Services, and in turn agencies such as NIDA and SAMHSA, will be Denny Rehberg of Montana. He has a mixed record on health and substance abuse issues, but only an 11% rating from the American Public Health Association. He cast a “no” vote on the House bill to enact the Wellstone/Domenici Parity act. He later voted “yes” on the final version, but the initial “no” vote is making many in the advocacy community very cautious.
Of course, all of this looks forward to FY 2012. In reality, the budget for FY 2011 has still not gone into effect. The government has been operating on what is known as a “continuing resolution” since September 30, 2010, at FY 2010 levels. Despite several attempts to pass the FY 2011 budget in the closing days of the 111th Congress, and the lame duck session this past December, it never came to fruition. This was due in large part to Republicans blocking the legislation in the Senate, knowing they would have a better chance to cut spending if they could postpone votes on the FY 2011 budget until the new Congress was sworn in. The current continuing resolution is in effect until March 4, 2011. If a budget, or new CR, is not passed before then, it will result in a government shutdown. That means any and all services reliant on government funds will cease to operate until a budget is passed. This could severely impact substance abuse services.
As far as health care reform is concerned, it is almost a sure thing that the entirety of the bill will not be repealed. With the Democrats in the Senate and the White House, there is no way that such legislation will pass. However, this does not mean that changes will not be forthcoming. What it comes down to is how certain provisions of the Affordable Care Act are being funded. Those parts that require appropriations over the next two years face trouble in the House. Even before the election, Republicans attempted to chip away at certain provisions via the Johanns amendment, which would have taken billions of dollars out of the Public Health and Prevention fund created by the act. The amendment was defeated, and $40 million allocated to SAMHSA for the integration of substance abuse treatment into primary care was preserved.
According to the National Council of Community Behavioral Health, we will likely see many proposals related to changing the health care reform law, and most concerning to the addiction and mental health community will be efforts to scale back, or delay the Medicaid expansion scheduled for 2014. We have already discussed that federal discretionary funding will not be growing, and that additional federal Medicaid assistance is unlikely. The consequences of these actions is to put further pressure on state and county appropriations, further eroding addiction and mental health funding for indigent populations.
A notable absence in the 112th Congress will be that of Rep. Patrick Kennedy, the undeniable Congressional champion for substance abuse treatment over the last decade. Following closely on the heels of Rep. Jim Ramstad’s retirement after the 111th Congress, the Addiction, Treatment, and Recovery Caucus has lost both its Democrat and Republican chairmen in a span of just two years. This means that Congress is now without a member whose top priority is substance abuse treatment and prevention. Many members of Congress are sympathetic to the issue, but none currently in Congress make it a top priority, save possibly one exception, Rep. Mary Bono-Mack of California, who has worked hard to become a visible leader on the issue. Rep. Tim Ryan of Ohio will be taking over as the Democratic chairman of the ATR caucus, joining Rep. John Sullivan of Oklahoma as the Republican chairman.
Without a doubt, it’s going to be an interesting and challenging two years!