Hurricanes Katrina

Order Code RS22292 October 5, 2005 CRS Report for Congress Received through the CRS Web Hurricanes Katrina & Rita: Addressing the Victims’ Mental Health and Substance Abuse Treatment Needs Erin D. Williams Specialist in Bioethical Policy Domestic Social Policy Division Summary The Department of Health and Human Services’ Substance Abuse & Mental Health Services Administration (SAMHSA) has three primary mechanisms of providing federal funding to meet the mental health and substance abuse prevention needs of victims of recent hurricanes: the Crisis Counseling Assistance and Training Program (CCP), SAMHSA Emergency Response Grants (SERG), and supplemental appropriations. CCPs may be of interest to Congress, as questions have arisen regarding their appropriate scope and duration following two previous large-scale emergency situations (the Oklahoma City bombing, and the September 11, 2001 terrorist attacks). SERG may also be of interest, as Congress may consider amending or suspending existing law to enhance the availability of grant money. Congress has already passed two supplemental appropriations . This may lead Congress to consider a range of oversight options. This report will be updated as needed. Introduction According to the Substance Abuse and Mental Health Services Administration (SAMHSA), Hurricanes Katrina and Rita may effect both the victims’ mental health and their substance abuse treatment needs. The mental health effects may be deep and linger for weeks and months to come. Almost everyone who lives through such an event experiences some feelings of sadness and depression. Depending on the individual, these feelings can vary in intensity and duration. This is true not only for the residents of the Gulf Coast cities and towns devastated by the hurricanes, but also for the thousands of rescue workers, emergency medical personnel, and disaster recovery experts engaged in one of the biggest search-and-rescue operations in United States history.1 1 “Hurricane Katrina and Disaster Relief Information,” SAMHSA website, at [http://www.mentalhealth.samhsa.gov/cmhs/katrina/], visited Sept. 14, 2005. Congressional Research Service ˜ The Library of Congress CRS-2 Issues related to substance abuse may also arise in the aftermath of Hurricanes Katrina and Rita.2 Those recovered or recovering from substance abuse problems face an increased risk of relapse following a disaster.3 Individuals dependent on opioids, including but not limited to heroin, may seek help from Opioid Treatment Programs (OTPs) as a result of the disruption in supply of street drugs. Persons previously involved in OTPs may also need assistance to ensure continuity of care, as both the local OTPs and individuals’ medical records may have been destroyed. As of September 9, 2005, seven OTPs serving over 1,000 patients in the New Orleans area were closed. Many of the patients may seek not only medication, but also other services such as crisis counseling, housing or employment counseling. SAMHSA , which is a part of the U.S. Department of Health and Human Services (HHS), is the federal agency with the primary responsibility for addressing the mental health and substance abuse treatment needs of those individuals impacted by the hurricanes. SAMHSA’s mission is to build resilience and facilitate recovery for people with or at risk for substance abuse and mental illness. The agency administers a combination of competitive, formula, and block grant programs that fund communitybased mental health and substance abuse treatment and prevention services. Disaster readiness and response is one of its 11 priority program areas.4 This report provides a brief overview of SAMHSA’s activities related to the hurricanes and discusses issues and options for Congress. It begins with some background on federal disaster assistance. How Does the Federal Government Generally Assist Disaster Victims?5 The central piece of legislation enabling federal assistance to disaster victims is the Robert T. Stafford Disaster Relief and Emergency Assistance Act of 1974.6 The Stafford Act authorizes the President to issue a major disaster declaration to speed a wide range of federal aid to states determined to be overwhelmed by hurricanes or other catastrophes. Section 416 authorizes the President to provide financial assistance to state or local agencies or private mental health organizations for professional counseling services, or training of disaster workers, to relieve major disaster victims’ mental health problems caused or aggravated by the disaster or its aftermath. Through executive orders, the 2 Unless otherwise noted, the information in this paragraph is from Charles G. Curie, SAMHSA Administrator, “A Letter from the SAMHSA Administrator - Guidance to the State Methadone Authorities (SMA) and Opioid Treatment Programs (OTP),” SAMHSA website (Sept. 9, 2005), at [http://www.samhsa.gov/Disaster/katrina_curie_050909.aspx], visited Sept. 14, 2005. 3 Dee S. Owens, “Substance Abuse Treatment Implications to Terrorism Events” SAMHSA website (Aug. 13, 2004), at [http://www.samhsa.gov/csatdisasterrecovery/lessons/saTreatmentImplicationsToTerrorismE vents.pdf], visited Sept. 14, 2005. 4 “About SAMHSA,” SAMHSA website, at [http://www.samhsa.gov/Menu/Level2_about.aspx], visited Sept. 14, 2005. 5 Information on the Stafford Act and the Disaster Relief Fund in this section are from CRS Report RL33053, Federal Stafford Act Disaster Assistance: Presidential Declarations, Eligible Activities, and Funding, by Keith Bea, at [http://www.congress.gov/erp/rl/pdf/RL33053.pdf]. 6 42 U.S.C. 5121, et seq. CRS-3 President has delegated to the Federal Emergency Management Agency (FEMA), within the Department of Homeland Security (DHS), responsibility for administering the major provisions of the Act. Through interagency agreement, SAMHSA generally administers the emergency programs related to mental health and substance abuse. Financing for Stafford Act aid is appropriated to the Disaster Relief Fund (DRF), administered by the Department of Homeland Security (DHS). Congress has passed two supplemental appropriations bills to provide additional money to meet hurricane assistance requests not covered by the current funds available in the DRF.7 How Is SAMHSA Assisting Victims Of Hurricanes Katrina & Rita? SAMHSA is participating in an interagency triage team with the Administration on Aging and the Administration for Children and Families, helping Federal Medical Shelters to provide staffing recommendations and service delivery.8 During the week of August 29, 2005, SAMHSA established a toll-free hotline for people in post-hurricane crisis,9 and activated the SAMHSA Emergency Response Center (SERC).10 SERC is a point of contact for all state mental health and substance abuse authorities, as well as all federal agencies and local mental health providers, to receive information and have access to resources, both in terms of staffing and resources to be deployed. It is also the coordinating body for the federal response overall for mental health and substance abuse issues prompted by Hurricanes Katrina and Rita. On August 31, SAMHSA’s Center for Substance Abuse Treatment (CSAT), Division of Pharmacologic Therapies, issued guidance to the State Methadone Authorities (SMA) and Opioid Treatment Programs (OTP) in hurricane affected states.11 The SAMHSA administrator has also issued guidance to all OTPs and States to assist them in providing short and long-term emergency methadone and buprenorphine treatment services to populations affected by the disaster, including patients in OTPs and persons dependent on opioids but not enrolled in addiction treatment. In conjunction with the above measures, SAMHSA has three primary mechanisms for providing funding to help address hurricane victims’ mental health needs, each of which is discussed below: the Crisis Counseling Assistance and Training Program (CCP), SAMHSA Emergency Response Grants (SERG), and supplemental appropriations. 7 For further information, see CRS Report RS 22239, Emergency Supplemental Appropriations for Hurricane Katrina Relief, by Jennifer E. Lake and Ralph M. Chite. 8 Charles Curie, “A Message from the SAMHSA Administrator,” SAMHSA website (Sept. 6, 2005), at [http://www.samhsa.gov/News/katrina_curie_message.aspx], visited Sept. 15, 2005. 9 “HHS Awards $600,000 in Emergency Mental Health Grants to Four States Devastated by Hurricane Katrina,” HHS News Release (Sept. 13, 2005), at [http://www.hhs.gov/news/press/2005pres/20050913b.html], visited Sept. 14, 2005. 10 Charles Curie, “Hurricane Katrina,” HHS Press Briefing (Sept. 9, 2005), at [http://www.hhs.gov/katrina/pressbriefingtranscript0907.html], visited Sept. 14, 2005. 11 “A Letter from the SAMHSA Administrator - Guidance to the State Methadone Authorities (SMA) and Opioid Treatment Programs (OTP),” SAMHSA website (Sept. 9, 2005), at [http://www.samhsa.gov/Disaster/katrina_curie_050909.aspx], visited Sept. 14, 2005. CRS-4 Crisis Counseling Assistance and Training Program (CCP).12 To provide funding of mental health assistance and training activities in presidentially declared disaster areas, SAMHSA administers the CCP through an interagency agreement with FEMA. Eligible entities (state mental health agencies and tribal authorities) work with SAMHSA to apply for and receive grants to provide counseling outreach and train local crisis counselors to provide assistance after federal relief workers leave the area. The CCP Immediate Services Program (ISP) provides funds for up to 60 days of services immediately following a disaster declaration; the Regular Services Program (RSP) provides funds for up to nine months following a disaster declaration. Services include education about typical disaster-related reactions, short-term individual and group counseling services, and referrals to other services (e.g., other disaster recovery agencies or organizations, substance abuse treatment, or traditional mental health treatment). CCP funds do not support long-term or traditional mental health or substance abuse services. As of October 4, 2005, SAMHSA had received thirty applications for post-hurricane CCP funding, and approved awards for fifteen: Alabama (2 awards; one for $668,395 and one for $895,714); Arkansas ($20,000 initially awarded, with other portions of the grant request pending); Arizona ($187,336); Colorado ($348,333); Florida ($1,461,517); Louisiana ($1 million initially awarded, with other portions of the grant request pending); Maryland ($111,499); Missouri ($542,250); Mississippi ($2,329,878); Nebraska ($46,789); Oklahoma ($365,568); Texas ($3 million initially awarded, with other portions of the grant request pending); Washington D.C. ($47,184); Wisconsin ($110,233); and West Virginia ($45,7910). The remaining fifteen applications were still under consideration. SAMHSA Emergency Response Grant (SERG). When local resources are overwhelmed and other resources are unavailable, SAMHSA is authorized under Public Health Service Act (PHSA) Section 501(m)13 to provide grants for crisis mental health and substance abuse services in accordance with SAMHSA’s Mental Health and Substance Abuse Emergency Response Criteria.14 Immediate Services grants and Intermediate Services grants are available to states, territories, and federally recognized tribal authorities. Previous examples where SERGs have been awarded include the Washington DC-area sniper incidents and the Rhode Island nightclub fire. SERGs totaling $600,000 are being made available for award to Louisiana ($200,000), Texas ($150,000), Mississippi ($150,000) and Alabama ($100,000) as part of SAMHSA’s immediate hurricane response.15 12 For detailed information about CCPs, see “Emergency Mental Health and Traumatic Stress Crisis Counseling Training and Assistance Program Guidance,” SAMHSA website, at [http://www.mentalhealth.samhsa.gov/cmhs/EmergencyServices/progguide.asp], visited Sept. 12, 2005. 13 In emergency situations, the PHSA allows the HHS Secretary to waive the usual requirements of a competitive grants process and a formal peer review of grant applications (as described in 42 USC §290aa-3). 42 USC §290aa(m). 14 66 FR 51873 (Oct. 11, 2001). 15 Source for dollar amounts: “HHS Awards $600,000 in Emergency Mental Health Grants to (continued...) CRS-5 Supplemental Appropriations. A portion of the supplemental funds appropriated by Congress to aid victims of Hurricanes Katrina and Rita may be used to supplement SAMHSA’s activities. These may be used to provide emergency mental health and substance abuse counseling and related services not addressed by the CCP, the SERG, or other existing funding. SAMHSA generally uses such funds to provide grants to state agencies and territory or tribal governments within affected areas. For example, substance abuse and mental health treatment services, psychotropic medication expenses, methadone treatment, suicide prevention programs, and major administrative expenses for mental health and substance abuse resulting from the disaster may be addressed through this mechanism. What Are The SAMHSA-Related Issues And Options For Congress Prompted By Hurricanes Katrina & Rita? CCP is Generally Short-term, Crisis-specific. The CCP is generally restricted to providing immediate crisis counseling for victims of disasters; it usually addresses neither ongoing mental health needs (such as the delayed emergence of post traumatic stress disorder), nor exacerbated pre-existing conditions. However, on two previous occasions the duration of CCP services has been extended: in Project Heartland (following the Oklahoma City bombing), and in Project Liberty (following the September 11, 2001 terrorist attacks).16 These extensions of service have prompted inquiries as to the appropriateness of providing funding for ongoing services, and what sort of oversight of the expenditure is appropriate for these services.17 SERG Availability is Limited by SAMHSA’s Fiscal Year. The enabling section of the PHSA allows SAMHSA to allocate up to 2.5% of its discretionary grant funds (appropriated from Congress) in a given fiscal year for SERG. Because the fiscal year ended on September 30, most of the funds had already been spent on other grants. Activities are now being funded under the terms of a Continuing Resolution. They are funded at the lower of three funding levels: the House-passed level, the Senate-passed level or the FY 2005 current rate, until their bill is signed into law or the CR expires. Congress might assist SAMHSA with future SERG by providing “no year funding” that may be spent or allocated without regard to SAMHSA’s fiscal year cycle. 15 (...continued) Four States Devastated by Hurricane Katrina,” HHS News Release (Sept. 13, 2005), at [http://www.hhs.gov/news/press/2005pres/20050913b.html], visited Sept. 14, 2005. 16 For further information about Project Heartland, see “Oklahoma’s Project Heartland,” CBS News (Apr. 17 2000), at [http://www.cbsnews.com/stories/2000/04/10/national/main182272.shtml], visited Sep. 14, 2005. For further information about Project Liberty, see “Project Liberty History,” New York State website (Oct. 21, 2004), at [http://www.projectliberty.state.ny.us/whatwaspl-history.htm], visited Sept. 14, 2005. 17 For example, see, “Federal Emergency Management Agency Crisis Counseling Grants Awarded to the State of New York after the Sept. 11 Terrorist Attacks,”(GAO-05-514), Government Accountability Office website (May 2005), at [http://www.gao.gov/new.items/d05514.pdf], visited Sept. 14, 2005. CRS-6 Appropriating Supplemental Funds for Disaster Relief Programs May Prompt Additional Congressional Oversight. Congress has the authority to conduct oversight following its appropriations, including supplemental appropriations like those it has made for the relief of victims of Hurricanes Katrina and Rita. In light of concerns about funding decisions after the hurricanes, Members of Congress may elect to exercise that oversight authority through informal communication between Congressional staff and agency representatives, formal hearings, follow-up reports, or through other mechanisms. Congressional oversight activities may be confounded by the effects of the hurricanes. For example, hurricane victims may be difficult to track as they cross state borders. Victims’ ongoing mental health and substance abuse needs may be difficult to ascertain because their medical records may have been destroyed or been made otherwise unavailable by the storms. Further issues may be created as victims who use mental health services provided by Medicaid move across state lines. Medicaid coverage of benefits varies from state to state, and it is not yet clear whether the Medicaid coverage rules of victims’ home or host state should apply.18 This constellation of issues complicates the task of ensuring that the appropriate amount of federal funding is directed toward meeting victims’ mental health and substance abuse needs. 18 For further information, see CRS Report RL33083, Hurricane Katrina: Medicaid Issues, by Evelyne Baumrucker, et al., at [http://www.congress.gov/erp/rl/pdf/RL33083.pdf].