Better Collaboration Necessary to Optimize New Funding Streams in Addiction Response

New funding sources present opportunities for improving the nation’s response to the addiction crisis, but strategies are needed to improve collaboration between agencies and various levels of government.

At the recent Rx and Illicit Drug Summit in Atlanta, Georgia, Regina LaBelle, Director of the Addiction and Public Policy Initiative at the O’Neill Institute at Georgetown University Law Center, Andrew Whitacre, an officer with Pew Charitable Trusts’ substance use prevention and treatment initiative, and Michele Gilbert, senior policy analyst for the Bipartisan Policy Center, presented a session on best practices for aligning spending to improve treatment outcomes and developing strategies to advance reform within the field.

While on site at the Summit, the trio spoke with Addiction Professional about the biggest barriers to cross-agency and cross-government collaboration, resources for discovering opportunities to better allocate funds, and the next steps that need to be taken.

Editor’s note: This interview has been edited for length and clarity.

Addiction Professional: What do you see as being the biggest barriers to cross-agency and cross-government collaboration in addressing the opioid overdose epidemic that we are currently facing?

Michele Gilbert: The biggest barrier to cross-agency collaboration just at the federal level is the silos that exist. A lot of the grants that are out there are very agency- and department-specific, because that's the structure of the government, and so that restricts how these agencies are incentivized to work together. There are efforts underway, for example, the Department of Health and Human Services (HHS) has a resurrected Behavioral Health Coordinating Council (BHCC), which looks across the HHS agencies only and brings them together on a variety of cross-cutting health topics, including behavioral health and primary care integration, workforce, data collection reporting—issues that are touching a bunch of different behavioral health topics. But outside of HHS, other than the Office of National Drug Control Policy (ONDCP), there aren't really interdepartmental entities that can oversee the breadth of opioid programs that are out there.

In terms of working with states, I think Andrew can speak to this a little bit more in detail, but there are just not a lot of opportunities for the federal government and state entities to really collaborate beyond what's required in the grants that they receive. And so outside of the onboarding, offboarding grant application reporting requirements and so on, there is just not a lot of space for that.

Andrew Whitacre: The way that the federal government has set up these streams of funds plays out in the way that state governments set up their departments and receive the money. There is a lack of coordination. With these agencies who are receiving the money, it's separate persons managing it. They have no obligation to coordinate with their peers and other agencies. They have different priorities, reporting requirements, and objectives, and that plays out in that lack of coordination. So, there's opportunities for states to [improve coordination]. They’re limited when the federal government requires different things, but pushing agencies, being proactive and saying, "These are our challenges that we're facing."

If you have shared priorities, if you're able to do that collaboration and say, "Here's a shared priority we have across agencies," seek waivers for funds that you're getting that would help reach those goals, and push them to grant waivers. The more states that push federal agencies to grant them, the more likely they are to grant a waiver because they're under that pressure from state governments.

I look at state to local, lack of collaboration is really important too, especially in the opioid settlement context because all these local governments are making these plans with funds that they’ve never had before. And a lot of times they’re making those decisions without full knowledge of what all the funds are that are available to them, so they’re spending money on things they may not need to spend money on.

There are potential policy implications where the states could make decisions and offload some of the money that the local governments are deciding to spend it on like things that Medicaid could be paying for. Well, push your state to pay for it so you don’t have to use your settlement dollars, and you can actually use it for things that Medicaid won’t pay for like harm reduction, infrastructure, investment, and things like that. The system is very siloed up and across.

MG: Yes, and if I could just end that up more on a positive note, I think there are opportunities to encourage collaboration through a process that we all call blending and braiding. What that means, just to operationalize it, is at the state level you can use, or entities can use their grant dollars to fill in gaps in their Medicaid coverage, and now the settlement dollars can also fill gaps in grants that the government won’t fund. And then at the federal level, going back to the interdepartmental piece, there are a lot of p’ograms that sound vaguely familiar. For example, SAMHSA has a first responder grant that teaches first responders to address overdoses in the field.

Meanwhile, the Department of Justice has very similar programs. There’s a pilot called the Comprehensive Opioid, Stimulant, and Substance Abuse Program (COSSAP), which also looks at the role of first responders in addressing emergency situations. So those sound very similar, why not bring them together in a way that’s constructive and it’s not taking away money from one agency or another. It’s really just maximizing the thought leadership within the agencies to be able to serve their grantees better.

Regina LaBelle: We have a report that is going to come out. It’s basically an analysis of the barriers that exist, and I think there are 2 main points. The first is that, often from a government standpoint, we look at things from what’s going to be most convenient for agencies as opposed to what will best serve the individual, and that takes a real sea change of approach, which will take a while. And then secondly, what creates a lot of these barriers are money, ego, and turf. Often, and it takes leadership to transcend those barriers, and I think we have some examples in state governments. I think Kentucky is a really good example of a state that has transcended political changes over time to extend out and expand a really robust addiction system for people.

AP: Andrew, you had mentioned that there are these dollars coming out of the opioid settlement that local governments are getting and are possibly allocating towards things that they don't necessarily need to be spending on, and these are initiatives that could be getting funded elsewhere. If you have local legislators who are not familiar with some of these opportunities, are there resources and folks that they should be turning to say, "Hey, what am I missing here?" Is there a better way to go about appropriating these funds that they received?

AW: Yeah. If you're a state legislator, I think it's an opportunity to say our state should be supporting local governments as they're making these plans. First of all, by maximizing our Medicaid benefit, there's a leadership role for state legislatures to take there. It's not just for the Medicaid director. They're a partner with the legislature and they can certainly push Medicaid program to cover those things. So, I think it's a recognition of, where are the state gaps that we can fill so that local governments don't have to fill the things that we have not. And so then they can push that down and say, "Well, we've made all these decisions, changes, spend these on things that Medicaid can't cover, we can't pay for them with the block grant and all these other funds that we have."

You know your communities best. Meet the needs of the communities. Stop having to fill gaps because we haven't made the policy decisions to fill those even though we could. So I think it's a leadership opportunity for legislators and governors to really step up, map their system, make some difficult choices, and put the local governments in a better position to spend those dollars in ways that are going to improve people's lives.

AP: Looking ahead, what next steps need to be taken to reform existing systems and improve collaboration?

MG: Liberating framework for sure. Going into the settlement piece, the settlements are between companies and states, and so the federal government doesn't have much of a space in there, but there can be a pretty good role for the federal government to. For example, issue guidance around what Medicaid can and can't do to enable states to maximize their Medicaid programs as much as possible. There can also be technical assistance and the share of information. The federal government's in a great position to be able to “un-silo” some of the emerging practices and best practices that are coming out of academia and other local demonstrations.

So, being a real resource for those folks is also a role that they can take to un-silo. Thinking long term, the recipients of settlement dollars, we did some work in the Bipartisan Policy Center to understand how we can pair federal grant dollars with the settlement dollars in a rural Appalachian area. What we found is these rural areas don't get a lot of federal grants, especially per capita, given the need that they have. So, we look at opportunities to invest their settlement dollars to enable them to get federal grants once the 18-year period is up and encourage sustainability.

AP: Is there anything else anyone wanted to add that we haven't touched on yet?

RL: Well, I think one other important piece is, North Carolina just expanded Medicaid. Medicaid plays a very important role in providing the basics and the foundation. The monies that are spent in Medicaid can extend a lot of the other funding that comes from grants because we can't do one-off grants and expect to build the kind of system that we need. We need that Medicaid expansion, we need parity enforcement. So, anything that helps build the foundation better, that's another next step.

Reference

LaBelle R, Whitacre A, Gilbert M. Aligning spending to improve outcomes and enhance the response to addiction. Presented at the Rx and Illicit Drug Summit; April 10-13; Atlanta, Georgia.