Federal Block Grant Research Articles

Do presidents favor co-partisan mayors in the allocation of federal grants?

Do presidents favor co-partisan mayors in the allocation of federal grants?

State Priorities and Needs: The Role of Block Grants.

Block grant funding provides federal financial support to states, with increased flexibility as to how those funds can be allocated at the community level. At the state level, block grant amounts and distributions are often based on outdated formulas that consider population measures and funding environments at the time of their creation. We describe variation in state-level funding allocations for 5 federal block grant programs and the extent to which funding aligns with the current needs of state populations. We conducted an analysis in 2022 of state block grant allocations as a function of state-level characteristics for 2015-2019 for all 50 states. We provide descriptive statistics of state block grant allocations and multivariate regression models for each program. Models include base characteristics relevant across programs plus supplemental characteristics based on program-specific goals and state population needs. Mean state block grant allocations per 1000 population by program ranged from $618 to $21 528 during 2015-2019. Characteristics associated with state allocations varied across block grants. For example, for every 1-percentage-point increase in the percentage of the population living in nonmetropolitan areas, Preventive Health and Health Services Block Grant funding was approximately $7 per 1000 population higher and Community Services Block Grant funding was approximately $40 per 1000 population higher. Few supplemental characteristics were associated with allocations. Current block grant funding does not align with state characteristics and needs. Future research should consider how funds are used at the state level or allocated to local agencies or organizations and compare state block grant allocations with other types of funding mechanisms, such as categorical funding.

Progress, Persistence, and Hope: Building a System of Services for CYSHCN and Their Families.

Progress, Persistence, and Hope: Building a System of Services for CYSHCN and Their Families.

Increased Medicaid Funding for Territories Urgently Needed, Experts Say

Increased Medicaid Funding for Territories Urgently Needed, Experts Say

Tucson Shares Blueprint for Crisis System Success

Tucson Shares Blueprint for Crisis System Success

State Variation in TANF Expenditures: Implications for Social Work and Social Policy.

The Temporary Assistance for Needy Families (TANF) program is a federal block grant to the states, with a required state contribution. Although often viewed as a cash assistance program with work requirements and services targeted at extremely low-income families with children, only about one-quarter of all state and federal TANF funds are now used for traditional cash aid. Uses of funds vary widely by state, and alternatives range from refundable tax credits to support of state child welfare systems. In this article, the author examines the relationship between state categorical TANF spending and key social, political, and economic characteristics using data from 2015 to 2017 and multilevel linear models. Racial and ethnic demographics of the cash assistance caseload are associated with differences in spending, with states with larger proportions of the caseload composed of people of color devoting a lower percentage of effort to traditional benefits and more to alternative cash transfers. Changes in unemployment rate within states are associated with greater spending on basic assistance and reduced spending on alternative transfers. These findings indicate that, although TANF cash benefits spending may be economically responsive within the program's overall flexible structure, spending patterns raise issues of equity for disadvantaged families.

Prominent researchers argue against more of the same in treatment funding

An over‐reliance on federal block grants and “one‐off” funding initiatives has left the addiction treatment system under‐resourced to respond to an addiction crisis that stands to be at least as deadly as COVID‐19 during the span of the Biden administration, a trio of prominent researchers argue in a newly released policy paper. The authors suggest that the new administration and Congress should prioritize efforts to build on what they consider the most impactful developments in improving access and quality in addiction treatment, such as Medicaid expansion and parity mandates.

State behavioral health agency website references to evidence-based program registers

PurposeEvidence-based program registers (EBPRs) are important tools for facilitating the use of evidence-based practices or programs (EBPs) by state statutory agencies responsible for behavioral healthcare, broadly defined as substance misuse, mental health, HIV/AIDS prevention, child welfare, and offender rehabilitation. There are currently no data on the purposes for which such state agencies reference EBPRs on their official websites. MethodA webscraping method was used to identify and classify relevant “hits”, defined as a state behavioral health webpage with single or multiple references to a study EBPR. A total of 778 hits (unique combinations of webpage and register) were coded. Up to three codes were applied to each hit for the “reasons for the EBPR reference” (EBPR use) dimension, one code was applied to each hit for the “purpose of the EBPR reference” and “intended audience of the webpage containing the hit” dimensions, and up to two codes were applied to each hit for the "funding mentions” dimension. ResultsThree EBPRs out of 28 accounted for 73.6% of the hits. The most frequent reason for referencing EBPRs were as a resource for selecting EBPs or validating existing programs and practices. The references tended to appear in reports from the state, in training materials, or guidelines. The references tended to address broad groups of behavioral healthcare professionals. EBPRs were frequently referenced in the context of federal block grants or other federal funding. ConclusionsIncreasing state agencies’ awareness and use of the entire range of existing EBPRs may improve implementation of EBPs nationally.

Improving Outcome Accountability of Block Grants: Lessons Learned From the Preventive Health and Health Services Block Grant Evaluation

The flexibility federal block grants provide recipients poses challenges for evaluation. These challenges include aggregating data on wide-ranging activities grant recipients implement and the outcomes they achieve. In 2014, we began designing an evaluation to address the challenges of assessing outcomes and to improve outcome accountability for the Preventive Health and Health Services Block Grant. Through the use of evaluability assessment methodology, review of existing data and the literature, and key informant interviews, we developed a measurement framework to assess outcomes resulting from recipients' ability to use grant funds to meet their locally prioritized needs. We argue our evaluation approach demonstrates that block grants, and other similarly flexible programs, can be evaluated through appropriately designed measures. Our efforts challenge the idea that flexibility presents an insurmountable barrier to evaluation and outcome accountability for federal block grants.

Improving quality and performance in substance use treatment programs: What is being done and why is it so hard?

As states plan to implement system-wide change of any kind, it is important to understand program directors' perspectives on challenges they face. This is especially true with quality improvement reforms. Much research has focused on quality improvement in medicine, but there is a gap in our knowledge about programs that treat individuals with drug or alcohol use. From 2007 to 2016, Maine contracted with selected substance use treatment programs using financial incentives to improve quality, with focus on treatment access, engagement, retention, and completion as measures of quality. Using surveys and in-depth interviews, this research documents strategies that programs used to improve performance and challenges faced in implementing reforms. Only programs that received federal block grant funding through the state to provide substance use treatment were eligible for an incentive contract, creating a natural experiment with non-block grant programs (non-incentive). Directors were interviewed in incentive (n=13) and non-incentive programs (n=12). Thematic analysis revealed that: 1) programs focused on QI, but those eligible for incentives focused on different quality measures, 2) most of the reforms in both groups targeted improving treatment access and retention, and 3) programs faced substantial challenges in undertaking reforms. Despite efforts, many programs could not meet quality measures consistently over time and faced barriers over which they had little control. Policy makers and program administrators will benefit from knowing the challenges of undertaking QI initiatives and provide support for the programs.

Integration of Care in the Implementation of the Affordable Care Act: Changes in Treatment Services in a National Sample of Centers Treating Substance Use Disorders

ABSTRACTThis study examined patterns of medicalization in substance use disorder (SUD) that are aligned with the goals of the Affordable Care Act (ACA). Using a nationally representative sample of SUD treatment programs, we examined changes in several treatment domains. While observed changes were modest, they were in directions that support the thrust of the ACA. Specifically, we found an increase in the percentage of treatment referrals from other health care providers. We found an increase in the number of physicians for programs that did have a physician on staff, and an increase in counselors certified in treating alcohol and drug addiction. There was significant growth in the availability of oral and injectable naltrexone but not of other pharmacotherapies. There was a decrease in support for the 12-step model and an increase on the emphasis of a medicalized treatment model. Finally, we found a shift away from federal block grants and other public funding, consistent with the expectations of the ACA. These data indicate that, while progress is slow, the environment of the recent past has been supportive of the goal of SUD treatment’s integration into mainstream medical care.

The influence of state-level policy environments on the activation of the Medicaid SBIRT reimbursement codes.

To examine how institutional constraints, comprising federal actions and states' substance abuse policy environments, influence states' decisions to activate Medicaid reimbursement codes for screening and brief intervention for risky substance use in the United States. A discrete-time duration model was used to estimate the effect of institutional constraints on the likelihood of activating the Medicaid reimbursement codes. Primary constraints included federal Screening, Brief Intervention and Referral to Treatment (SBIRT) grant funding, substance abuse priority, economic climate, political climate and interstate diffusion. Study data came from publicly available secondary data sources. Federal SBIRT grant funding did not affect significantly the likelihood of activation (P=0.628). A $1 increase in per-capita block grant funding was associated with a 10-percentage point reduction in the likelihood of activation (P=0.003) and a $1 increase in per-capita state substance use disorder expenditures was associated with a 2-percentage point increase in the likelihood of activation (P=0.004). States with enacted parity laws (P=0.016) and a Democratic-controlled state government were also more likely to activate the codes. In the United States, the determinants of state activation of Medicaid Screening, Brief Intervention and Referral to Treatment (SBIRT) reimbursement codes are complex, and include more than financial considerations. Federal block grant funding is a strong disincentive to activating the SBIRT reimbursement codes, while more direct federal SBIRT grant funding has no detectable effects.

Measurement of Childhood Serious Emotional Disturbance: State of the Science and Issues for Consideration

Surveys suggest that between 4.3% and 11.5% of children living in the United States have a serious emotional disturbance (SED). SED is defined in the Federal Register, and federal block grants are allocated to states based on the prevalence of SED. Accurate measurement of SED is critical, yet surveys have used different methodologies and instrumentation to obtain prevalence estimates. Two expert panels were convened by the Substance Abuse and Mental Health Services Administration (SAMHSA) in the fall of 2014 to discuss the current state of the field in operationalizing and measuring SED. The aims of this article are to (a) provide an update on SED prevalence rates from survey research, (b) summarize key discussion points that emerged during the SAMHSA expert panel meetings, and (c) make specific recommendations for next steps in measuring the prevalence of SED. Issues addressed in this article are important not only for federal allocation of service dollars to meet the needs of children with SED, but also for broader mental health surveillance efforts within the context of large national research surveys.

Are FQHCs the Solution to Care Access for Underserved Children?

* Abbreviations: ED — : emergency department FQHC — : federally qualified health center PCP — : primary care provider In this issue of Pediatrics , Nath and colleagues1 present an ecological analysis of federally qualified health centers (FQHCs) in California, looking at how Medicaid and uninsured children use emergency departments (EDs). The article is timely because the Affordable Care Act and many state policymakers have bet on FQHCs as the solution to improving health care access for low-income populations while also reducing costs. The central issue, however, is how we ensure that poor children receive the same standard of care as others. FQHCs are health care delivery sites funded by states through federal block grants to provide primary care and related services, such as behavioral health, dental care, and transportation, to low-income and medically underserved communities. From just a few centers, there are now 1202 licensed FQHCs with >10 000 sites serving >20 million persons across the United States.2 This growth is likely to continue for several reasons. First, many pediatricians and other primary care providers (PCPs) either refuse to accept or severely limit Medicaid patients in their panels because of low reimbursement … Address correspondence to Kelly J. Kelleher, MD, MPH, Department of Pediatrics, Nationwide Children’s Hospital, 700 Children’s Dr, FB3145, Columbus, OH 43205. E-mail: kelly.kelleher{at}nationwidechildrens.org

Complex Grant-Contracting and Social Equity: Barriers to Municipal Access in Federal Block Grant Programs

ABSTRACT:Intergovernmental granting involves complex vertical and horizontal contracting problems. The implementation of some federal social equity programs is a function, in part, of the ability of local governments to contract out. Municipalities with less administrative capacity or in high-contracting-cost environments face barriers to funding. We theorize that in some cases these problems affect equitable access to federal funding and apply this framework to the state-administered nonentitlement Community Development Block Grant (NE-CDBG) program. Utilizing a zero-inflated negative binomial regression, we examine 250 small municipal governments to test the relationship between number of NE-CDBGs grants awarded in 2000–2003 and obstacles to contracting out. Our findings suggest that needs-based access to federal funds is distorted when small cities face obstacles to contracting out as a local managerial strategy. Competitive grant processes and the council-manager form of government also influence grant access, but low- to moderate-income populations do not track the number of grants in an expected direction. Our findings highlight concerns about the ability of small municipalities to access intergovernmental grant programs.

FROM WELFARE TO A WORK‐BASED SAFETY NET: AN INCOMPLETE TRANSITION

The passage of the 1996 Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA), which we label welfare reform, decisively “ended welfare as we knew it” by eliminating the federal entitlement to cash assistance that Aid to Families with Dependent Children (AFDC) had provided for 60 years. The new cash assistance program, Temporary Assistance for Needy Families (TANF), is a fixed federal block grant that allows states to spend federal and state funds flexibly on cash assistance or a range of other services provided to needy families with children. PRWORA requires only that states enforce participation in work or work-related activities and impose time limits on the receipt of cash assistance from federal funds. Because it is not an entitlement program, TANF does not require states to provide benefits to all eligible families, nor does it require them to assume responsibility for guaranteeing unemployed recipients who reach their time limit a job if they cannot find one. As a result, the transition to the new “work-based safety net” remains incomplete: neither thefederal government nor the statesreplaced theentitlement to cash assistance with an entitlement to participate in work or work-related activities. TANF includes incentives that encourage states to minimize their cash assistance caseloads, even when recessions increase the number of eligible families. First, the amount of block grant funds has not changed since the program was enacted. A state’s allocation is not responsive to population growth or increased economic hardship. Second, funds not used for cash assistance can be reallocated to other related purposes. Third, states can satisfy the work participation benchmarks either by getting more recipients into work-related activities or jobs (which can be expensive) or simply by keeping caseloads small. In contrast to this reduction in public responsibility, TANF requires more responsibility from recipients. Indeed, it achieved its goal of eliminating long-term dependence on cash assistance. A recipient can no longer reject a job offer and continue to receive cash assistance. If she does not cooperate with the welfare agency, she can be sanctioned and her family can be removed from the welfare rolls. She can also be removed when she reaches her time limit, even if she is actively seeking work and willing to work for her cash assistance.

Block Grants and Education Expenditure

This article investigates the effects of block grants on education expenditures using panel data from Canadian provinces over the period 1982 to 2008. Our main empirical identification strategy relies on the use of the allocation formula for equalization grant—a component of the Canadian federal block grant. The results indicate that block grants have stimulative effects on provincial education expenditure. Our results suggest that a one dollar increase in per capita federal grants is associated with an increase in per capita education expenditure of about Can$0.21, which is roughly proportional to the share of education in total provincial spending. The results are robust to various sensitivity checks.

Limitations, Legacies, and Lessons

Over the past two decades, federal block grants and spatially targeted tax subsidies have become popular forms of federal assistance to disaster-affected areas. This article provides an overview and critical evaluation of the impact of the Gulf Opportunity Zone and the Community Development Block Grant–Disaster Recovery program in the years after Hurricane Katrina. I focus particular attention on the limitations, problems, and inequality reinforcing characteristics of the two programs. The experience in the Gulf South suggests that the effectiveness of the Community Development Block Grant program and spatially targeted tax incentives could be enhanced if policy makers build in clear rules and procedures for delivery of aid, enforce antidiscrimination statutes and fair housing laws, and exercise strong oversight over program implementation at the state and local levels. I conclude that the success of federal disaster recovery programs in realizing their recovery goals depends on political efforts to reduce class and racial inequalities and promote social justice.

Early psychosis intervention services: a work in progress.

Early psychosis intervention services: a work in progress.

Implications for services and policy.

The effectiveness of the Early Detection and Intervention for the Prevention of Psychosis Program (EDIPPP) reported by McFarlane and his colleagues is welcome news for policy makers in behavioral health services delivery circles. They will be encouraged that a multielement intervention is superior to usual care on a wide range of important outcomes, such as symptoms and functioning, and that conversion rates to psychosis are lower, as well. Policy makers will nod with appreciation that populations in 6 population areas were surveyed to identify individuals to participate in the intervention, which was implemented with fidelity in these communities. These findings are admired by policy makers, as well as scientists, because they have both internal and external validity, and they are relevant to considerations for allocating scarce resources for behavioral health services. Before continuing with our comment, we issue a warning about calling this intervention FACT, family assertive community treatment. We suggest that this is a poor choice, as the program only resembles ACT in its team structure, and the term, FACT, has been used for years to designate a “forensic” version of ACT, focused on individuals with well-established psychosis who are involved in the criminal justice system. The landscape of early intervention services is already covered with new terms with considerable overlap in their components, so this confusion will hamper understanding of the intervention and could delay adoption of a new practice. We suggest that the field refer to one term, such as Coordinated Specialty Care (CSC), and then specify the target population for the multielement intervention, first-episode of psychosis, clinical high risk, ultra-high risk, or attenuated psychosis syndrome. Whatever we decide to call these interventions, the most relevant questions for policy makers are about how to target and implement the services. The 5% supplement of the federal block grant for early intervention services will enable States to expand the implementation of CSC with a focus on first-episode care. This is the approach with the greatest evidence, and with block grant support, the greatest momentum. We believe that spread and quality monitoring should be the first priority—for services for adult mental illness, broadly, and for early intervention services, specifically. Successful implementation with fidelity, as well as adequate financing for EDIPPP-type services, will motivate policy makers and advocates to push the limits of early intervention. Paying for early intervention beyond the block grant is an urgent priority. Some components of CSC, such as psychotherapy and medications, can be covered by health insurance, whereas other elements, such as supported education and employment, cannot be covered by conventional insurance and only occasionally by Medicaid. Public behavioral health dollars, such as State and local appropriations, can fill some of the gaps, but these resources are quite limited. Funding for training and monitoring fidelity and implementation is even scarcer. Filling both of these gaps is essential to achieving access to these important services.