Blueprint for a National Prevention Infrastructure for Mental, Emotional, and Behavioral Disorders (2025) / Chapter Skim
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Appendix C: Mental Health and Substance Use Disorder Prevention Financing Landscape Analysis
Appendix C: Mental Health and Substance Use Disorder Prevention Financing Landscape Analysis
Pages 267-310
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Mark, Ph.D., M.B.A. RTI International TMark@RTI.org July 30, 2024 TABLE OF CONTENTS MENTAL HEALTH AND SUBSTANCE USE DISORDER PREVENTION FINANCING LANDSCAPE ANALYSIS 267 Table of Contents 267 INTRODUCTION 270 Background 270 Purpose of the paper 271 Methods 271 FEDERAL SPENDING ON BH PREVENTION 274 Federal Spending Overview 274 Discretionary Versus Mandatory Funding 275 Prevention and Public Health Fund 276 Total Federal Spending on Prevention 277 Total Federal Spending on SuD Prevention 277 Total Federal Spending on MH Disorder Prevention 279 Total Federal Spending on BH (MH/SUD)
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287 TABLE 8 SAMHSA total mental health funding and mental health disorder prevention funding, fiscal year 2023 (millions)
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299 TABLE 15 HRSA mental health disorder prevention funding, fiscal year 2023 (millions) 299 TABLE 16 State primary substance use disorder prevention spending, 2023 (millions)
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. These trends require a new examination of the nation's MH/SUD prevention infrastructure and financing.
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The paper also discusses options to generate sustained and adequate funding for the prevention infrastructure. METHODS Defining MH/SUD This paper relies on the definitions and criteria in the American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders Version 5 (DSM-V)
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Defining MH/SUD Prevention Interventions National Academies of Sciences, Engineering, and Medicine reports have called out the challenge of defining BH prevention. This paper focuses on programs that were clearly identified as aiming to prevent MH/SUD or described as preventing adverse childhood experiences (ACEs)
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Most federal MH/SUD prevention programs are discretionary grant programs that allow spending on a combination of prevention and treatment with no requirements or accounting for how much funding was allocated to either. If a program appeared to be primarily for treatment, it was excluded from the spending estimates, but this determination was often difficult.
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FEDERAL SPENDING ON BH PREVENTION Federal Spending Overview As context for understanding the size of federal investment in MH/SUD prevention, it is useful to first describe total federal spending. In fiscal year 2023, outlays were approximately $6 trillion in total (23 percent of the nation's gross domestic product)
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. Primary prevention services are funded largely though discretionary mechanisms, such as block grants, as opposed to mandatory funding streams, such as Medicaid and Medicare entitlement programs.
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. A Congressional Research Service analysis found that the Prevention and Public Health Fund did not result in an increase in CDC funding (a proxy for public health prevention funding in general)
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Total Federal Spending on SUD Prevention The Office of National Drug Control Policy (ONDCP) , established by the Anti-Drug Abuse Act of 1988 and reauthorized by the SUPPORT for Patients and Communities Act (Public Law 115-271)
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National Drug Control Program Agency Funding Amount Funding Amount AmeriCorps $13.1 $13.1 Court Services and Offender Supervision Agency $27.9 $27.9 Department of Defense Drug Interdiction and Counterdrug Activities $130.1 Department of Education $108.7 $108.7 Department of Health and Human Services Administration for Children and Families $20 $20 Centers for Disease Control and Prevention $528.6 $528.6 Centers for Medicare and Medicaid Services $41.0 Food and Drug Administration $12.5 $12.5 Health Resources and Services Administration $142 $142 Indian Health Service $34.8 $34.8 National Institute on Alcohol Abuse and Alcoholism $66.4 National Institute on Drug Abuse $621.8 Substance Use and Mental Health Services $785.1 $638.4 Administration Department of Justice Bureau of Alcohol, Tobacco, and Firearms $0.1 $0.1 Bureau of Prisons $0.3 $0.3 Drug Enforcement Administration $4.7 $4.7 Federal Bureau of Investigation $0.1 $0.1 Office of Justice Programs $34.1 $34.1 Department of Labor Employment and Training Administration $6 $6 Office of Workers' Compensation Programs $7.8 $7.8 Department of the Interior Bureau of Indian Affairs $1 $1 Department of Transportation Federal Aviation Administration $17.8 $17.8 National Highway Traffic Safety Administration $17.6 $17.6 Office of National Drug Control Policy $151.8 $151.8 TOTAL $2,732 $1,808 Source: Office of National Control Policy. National Drug Control Budget, FY 2024 Funding Highlights, March 2023.
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Agency Funding Amount Substance Abuse and Mental Health Services Administration $919 U.S. Centers for Disease Control and Prevention $204 Centers for Medicaid and Medicare Services Not known Administration for Children and Families $1,126 Health Resources and Services Administration $517 Total $2,766 Source: Author calculation based on Department of Health and Human Services fiscal year, 2024, justification of estimates for Appropriations Committees.
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280 PREVENTION INFRASTRUCTURE FOR MEB DISORDERS TABLE 5 Federal substance use and mental health disorder prevention funding, fiscal year 2023 (millions) Substance Mental Combined Mental Use Health Health and National Drug Control Prevention Prevention Substance Use Program Agency Spending Spending Disorder Spending AmeriCorps $13.10 $13 Court Services and Offender $27.90 $28 Supervision Agency Department of Defense $0 Drug Interdiction and Counterdrug $0 Activities Department of Education $108.70 $109 Department of Health and Human $0 Services Administration for Children and $20 $1,126 $1,146 Families Centers for Disease Control and $528.6 $204 $732.6 Prevention Centers for Medicare and Medicaid $41.00 $41 Services Food and Drug Administration $12.50 $13 Health Resources and Services $142 $517 $659 Administration Indian Health Service $34.80 $35 National Institute on Alcohol Abuse $0 and Alcoholism National Institute on Drug Abuse $0 Substance Use and Mental Health $638.40 $919 $1,557 Services Administration Department of Justice $0 Bureau of Alcohol, Tobacco, and $0.10 $0 Firearms Bureau of Prisons $0.30 $0 Drug Enforcement Administration $4.70 $5 Federal Bureau of Investigation $0.10 $0 Office of Justice Programs $34.10 $34 Department of Labor $0 Employment and Training $6 $6 Administration Office of Workers' Compensation $7.80 $8 Programs
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HHS Agency Funding Centers for Medicare & Medicaid Services $1,593,907 Administration for Children and Families $8,977 National Institutes of Health $48,952 Health Resources and Services Administration $14,705 Centers for Disease Control and Prevention $10,979 Indian Health Service $7,994 Substance Abuse and Mental Health Services Administration $7,574 Public Health and Social Services Emergency Fund Authority $3,792 Food and Drug Administration $3,644 Administration for Community Living $2,525 Agency for Healthcare Research and Quality $485 Total $1,773,525 Source: https://www.hhs.gov/sites/default/files/fy-2024-budget-in-brief.pdf
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These legislative restrictions drive spending on health care services to people who are acutely or chronically ill and limit the ability of Medicaid to finance a broader array of effective population-based, primary MH/SUD prevention interventions. It reimburses for some prevention services if delivered by appropriately credentialed providers.
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. States could expand their HSIs to include social marketing campaigns on alcohol and drug use and other population-level BH prevention interventions.
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Therefore, it cannot be used for primary prevention activities, such as social marketing campaigns to prevent overdoses. BH Prevention Focused on Parents MH/SUD conditions can profoundly interfere with parenting.
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. Congress and federal agencies are encouraging greater coordination between Medicaid and child welfare to prevent family separations and child maltreatment and neglect (MACPAC, 2015)
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, which all address service delivery. To encourage greater focus on MH/SUD prevention by Medicaid managed care plans, CMS could create quality measures that focus on population health, such as the percentage of a state's population that died by suicide or had depression.
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Additionally, states are required to allocated 20 percent of the CSAT Substance Use Prevention, Treatment, and Recovery Services Block Grant to SUD prevention. In FY 2020, it equaled $2.008 billion; 20 percent of that is $401 million.
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SAMHSA MH Disorder Prevention Programs The majority of SAMHSA's prevention funding went toward preventing suicide and developing the crisis system ($617 million of $912 million, or 67 percent)
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APPENDIX C 289 TABLE 8 SAMHSA total mental health funding and mental health disorder prevention funding, fiscal year 2023 (millions) Specific Programs All Programs of Regional and Prevention Programs Funding Amount National Significance Programs Programs of Regional and National $1,044 Significance Project AWARE $140 $140 Mental Health Awareness Training $27 Healthy Transitions $30 Children and Family Programs $7 $7 Consumer and Family Network $4 Grants MH System Transformation and $3 Health Reform Project LAUNCH $25 $25 Primary and Behavioral Health $55 Care Integration Suicide Prevention Programs $617 $617 Homelessness Prevention Programs $33 Criminal and Juvenile Justice $22 Programs Assertive Community Treatment for $9 Individuals with SMI Minority Aids $9 Seclusion and Restraint $1 Tribal Behavioral Health Grants $22 $22 Infant and Early Childhood Mental $15 $15 Health Interagency Task Force on Trauma- $2 Informed Care Primary and Behavioral Health $1 Care Integration TTA Practice Improvement and Training $7 Consumer and Consumer Support $1 TA Centers Disaster Response $1 Homelessness Prevention Programs $2 MH Minority Fellowship Program $11 continued
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https://www.samhsa.gov/sites/default/files/samhsa-fy-2024-cj.pdf adults and/or youth with mental illness from the criminal or juvenile justice systems to community-based MH and SUD and other supports before arrest and booking. Table 9 provides a brief description of the purpose of the programs listed in Table 8.
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Health (BH) Care Integration Suicide Prevention These include 988 Suicide and Crisis Lifeline and Behavioral Health Programs Crisis Services; National Strategy for Suicide Prevention and Zero Suicide grant programs; and interventions that focus on youth suicide prevention, such as the Garrett Lee Smith and American Indian/Alaska Native (AI/AN)
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Infant and Early Supports two programs: the Infant and Early Childhood Mental Childhood Mental Health grant program and Center of Excellence for Infant and Health Early Childhood Mental Health Consultation. The purpose of the former is to improve outcomes using a prevention-based approach that pairs a MH consultant with adults who work with infants and young children in the different settings where they learn and grow, such as child care, preschool, home visiting, early intervention, and their home.
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Protection and Ensures that the most vulnerable individuals with SMI and Advocacy for significant emotional impairment, especially those in public and Individuals with private residential care and treatment facilities, are free from abuse, Mental Illness including inappropriate restraint and seclusion, neglect, and rights violations while receiving appropriate SMI treatment and discharge planning services. Source: Department of Health and Human Services Fiscal Year 2024, Substance Abuse and Mental Health Services Administration, Justification of Estimates for Appropriations Committees.
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294 PREVENTION INFRASTRUCTURE FOR MEB DISORDERS TABLE 10 CDC total funding and mental health/substance use disorder prevention funding, fiscal year 2023 (millions) MH/SUD Prevention Programs All Funding Funding Immunization and Respiratory Diseases $499 HIV/AIDS, Viral Hepatitis, STI and TB Prevention $1,391 School Health -- HIV $38 Emerging Zoonotic Infectious Diseases $698 Chronic Disease and Health Promotion $1,175 School Health $19 Excessive Alcohol Use $6 Social Determinants of Health $8 Birth Defects, Developmental Disabilities, $205 Disability and Health Fetal Alcohol Syndrome $11 Environmental Health $229 Injury Prevention and Control $761 Domestic Violence $38 Youth and Community Violence Prevention $18 Domestic Violence Community Projects $7 Rape Prevention $61 Suicide Prevention $30 Adverse Childhood Experiences $9 Opioid Abuse and Overdose Prevention and Surveillance $505 Firearm Injury and Mortality Prevention Research $12 Public Health Scientific Services $754 Occupational Safety and Health $362 Global Health $692 Public Health Preparedness and Response $905 Crosscutting Activities and Program Support $563 Buildings and Facilities $40 TOTAL $8,274 $762 Sources: Department of Health and Human Services Fiscal Year 2024, Centers for D isease Control and Prevention, Justification of Estimates for Appropriations Committees.
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The majority of CDC's drug use prevention funding is allocated toward surveillance and research rather than primary prevention interventions. CDC budgeted approximately $17.5 million toward preventing alcohol use and fetal alcohol syndrome.
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$9 Firearm injury and mortality prevention research $12 What works in schools $2 School health $19 TOTAL $204 Source: Department of Health and Human Services Fiscal Year 2024, Centers for Disease Control and Prevention, Justification of Estimates for Appropriations Committees. https://www.
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Administration on Children and Families mental health prevention funding, fiscal year 2023 (millions) Program Funding Amount Promoting Safe and Stable Families $325 Child Welfare Services $268 Family Violence Prevention and Services $240 Child Abuse Prevention and Treatment Act State Grants $105 Child Abuse Discretionary Activities $38 Community-Based Child Abuse Prevention $70 Native American Programs $60 National Domestic Violence Hotline $20 Total $1,126 Source: Department of Health and Human Services Fiscal Year 2024, Administration for Children and Families, Justification of Estimates for Appropriations Committees.
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. in high-need rural communities by establishing, expanding, and sustaining prevention, treatment, and recovery services"; $54 million was for SUD prevention delivered through HRSA's health center program (ONDCP, 2023c, p.
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. TABLE 15 HRSA mental health disorder prevention funding, fiscal year 2023 (millions)
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Title III-D funding does not appear to be used to focus on preventing MH/SUD but could be used to expand ACL's focus on BH prevention in older adults. DEPARTMENT OF EDUCATION In 2023, the Department of Education reported budgeting $108.7 million for SUD prevention, allocated to implement "evidence-based, multi-tiered behavioral frameworks" for "improving behavioral outcomes and learning conditions for students" (ONDCP, 2023b)
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TABLE 16 State primary substance use disorder prevention spending, 2023 (millions) Source Funding Amount Substance Use Prevention, Treatment, and Recovery Services Block Grant $364 Funds Medicaid $721 Other federal funds $255 State funds $118 Local funds $3 Other funds $3 Total $1,464 Source: SAMHSA: WebBGAS (samhsa.gov)
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Expanding State Spending on BH Prevention Through Earmarked Taxes One option for expanding MH/SUD prevention spending is earmarked taxes. A 2023 study found that "approximately 30 percent of the U.S.
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. As with many prevention funding sources, there is a need to ensure that the taxes are being used to fund evidence-based prevention activities.
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. According to CDC, key principles to develop a well-defined alcohol- and drug-free workplace policy include publicizing the policies and ensuring that employees are know that substance misuse is never permitted in the workplace; implementing workplace health promotion programs, including education on substance misuse; and offering employee assistance programs, which provide assessment, counseling, and referral for employees regarding substance misuse.
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2022. FY 2023 Justification of Estimates for Appropriations Committees https://acl.gov/ sites/default/files/about-acl/2022-02/FY2023_ACL-BudgetJustification.docx (accessed January 13, 2025)
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n.d.-b. Injury center suicide prevention funding.
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Preliminary observations on the 2022 national drug control policy. https://www.gao.gov/assets/gao-22-106087.pdf (accessed June 1, 2024)
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https://www.medicaid.gov/resources for-states/medicaid-state-technical-assistance/medicaid-and-school-based-services/index. html (accessed January 3, 2025)
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:e1001349. ONDCP (Office of National Drug Control Policy)
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2021. School-based depression and anxiety prevention programs: An updated systematic review and meta-analysis.
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