Priorities - to ensure that language in the SAMHSA Strategic Priority on Health Reform includes: promotion of cultural and linguistic competence in the provision of quality services, the targeting and expansion of enrollment services to populations at risk, and in the communications and outreach to diverse stakeholders regarding health care reform and parity.
- The use of technology (i.e., electronic health records) and expansion of services such as medical home are designed to address population differences and are culturally and linguistically competent
- Monitoring of quality track indicators not only in the use of health care services, but also in differences between populations at risk in their access to and utilization of services under health care reform.

As SAMHSA implements several provisions of the Affordable Care Act, substantial changes to block grants to support recovery and resilience are anticipated. In order to address the unique needs of older adults with mental illness and substance abuse issues, it is important that older Americans be identified as a distinct population in the development and enhancement of prevention and treatment programs. A thoughtful and concerted focus on the mental health and substance use problems of this population is essential.

Strong collaboration among federal, state, and local partners focused on aging health and human services, including the Administration on Aging and its network of state and community-based organizations, offers great promise for effectively addressing the prevention and treatment of mental health and substance abuse issues in older adults. In order to accomplish this, an older adult services workgroup could be added to Goal 4.4, Objective 4.4.3, Action Step 1.

Therapeutic Communities of America (TCA) is pleased to have the opportunity to submit comments to SAMHSA on the “Leading Change: A Plan for SAMHSA’s Roles and Actions 2011-2014” document. It is our hope that our comments will inform the discussion at SAMHSA and across agencies at the Department of Health and Human Services, as well as at other federal departments and agencies, and result in positive outcomes for people in and/or seeking recovery.

Therapeutic Communities of America (TCA) was founded in 1975 as a non-profit membership association for therapeutic communities across the United States and Canada. Since then TCA has grown to a consortium of over 650 substance abuse and mental health treatment programs run by 51 non- profit agencies located in 32 states, Washington DC, Puerto Rico, Guam, Virgin Islands, and Canada. The therapeutic methodology of treatment was established in the 1950’s addressing the entire social, psychological, cognitive, and behavioral factors in combating drug and alcohol abuse. TCA member agencies provide services to clients with a diversity of special needs as well as a continuum of care including such services as assessment, detoxification, ER triage, community residential care, in-prison programs, case management, outpatient, family therapy, transitional housing, education, vocational, primary medical services and continuing care. Therapeutic Communities have been leaders, creating innovations in addiction treatment including but not limited to services to addicted women and their children, individuals with co-occurring disorders and clients of the criminal justice system.

TCA commends SAMHSA for conducting this strategic planning process which will guide it as it seeks to fulfill its mission of reducing the impact that substance abuse and mental illness have on America’s communities. As you proceed with this endeavor, TCA respectfully requests that you consider our specific comments and recommendations on Strategic Initiative #4: Health Care Reform.

Goal 4.1: Assure behavioral health is included in all aspects of Health Care Reform (HCR) implementation
• Objective 4.1.1: Implementation strategies that address critical provisions in the Affordable Care Act
o Action Step 4: Develop recommendations to HHS regarding the mental health and addiction services that should be available to individuals that receive services through essential and benchmark plans.

Comment:

TCA believes that long term recovery requires the availability of a full continuum of addiction treatment and recovery support services. As supported in research, an effective addiction treatment system insures that services are timely, at the appropriate level of care and intensity, for the needed duration. As SAMHSA makes recommendations to HHS regarding the services that should be available to individuals under the essential and benchmark plans, TCA believes that it is essential that individuals have access to the full continuum of services including non-hospital addiction treatment: detoxification, short and long term rehabilitation, and in particular, therapeutic communities for those that need habilitation.

Goal 4.2: Support Federal, State, and Territorial efforts to develop and implement new provisions under Medicaid/Medicare.
• Objective 4.2.1: Increase SAMHSA staff’s understanding of current Medicaid program coverage and potential impact of HCR on States, Territories, and Tribes.
o Action Step 3: Identify current Medicaid services coverage issues that will remain even after implementation of health reform and parity.

Comment:

Even with implementation of the Affordable Care Act and all that it will accomplish to increase access to comprehensive health care services, Medicaid funds are presently not available to individuals between the ages of 24 and 64 for certain alcohol and drug addiction community-based residential treatment services. This policy is not changed under the provisions of the Affordable Care Act.

Any effort to expand overall access to treatment must include Medicaid reimbursed residential treatment. The IMD exclusion is a significant barrier to many who seek appropriate and effective substance abuse treatment. Those with substance abuse disorders must have the full range of treatment options available to them, including valuable services offered by therapeutic communities. Americans who are Medicaid eligible should not be denied access to needed services in a therapeutic community. Such exclusions hinder the individual and society from reaching positive sustained health and self sufficiency outcomes that have been demonstrated through research. Eliminating the IMD exclusion would make health care policy more equitable and help people access needed residential drug treatment.

TCA urges SAMHSA to fix this barrier to care by working with the Centers for Medicare and Medicaid Services to end the IMD exclusion. If the IMD exclusion were corrected, many Americans already disenfranchised in the public health, social services, and criminal justice systems could be identified and properly treated for the disease of substance use disorder, which may be their greatest barrier to self sufficiency.

Goal 4.4: Develop changes in SAMHSA Block Grants to support recovery and resilience
• Objective 4.4.2: Develop recommendations for spending changes.
o Action Step: 2 Project services that will be covered under third party reimbursement.
o Action Step 3: Identify service specific categories for use of Block Grant funds.

Comment:

TCA believes that the Substance Abuse Prevention and Treatment Block Grant (SAPTBG) is a critical safety net for that addresses substance abuse as a distinct and primary disease. Addiction is a primary disease that requires distinct strategies for treatment, prevention and recovery. The SAPTBG serves many who have been disenfranchised from other services – and who would otherwise not receive services, even after implementation of the Affordable Care Act.

Because TCA members have a long standing history of serving populations that have limited or no funding available, it is essential that the SAPT block grant continue to be authorized in order to provide services to those addicted individuals who fall through the cracks of healthcare reform, especially during the time of transition.

As part of ensuring access to these services, SAMHSA must identify and include the full continuum of services including non-hospital addiction treatment: detoxification, short and long term rehabilitation, and in particular, therapeutic communities for those that need habilitation, in the services categories for use of Block Grant funds in any modified version of the SAPTBG.

Please call Dr. Sushma Taylor, President of TCA at the TCA National Office at 202-296-3503, if you need additional information or comments. Thank you again for the opportunity to provide feedback. TCA looks forward to working with SAMHSA on this very important initiative.

Sincerely,

Dr. Sushma Taylor
President
Therapeutic Communities of America