CLEVELAND, Ohio – The Alcohol, Drug Addiction and Mental Health Services Board of Cuyahoga County has been a lightning rod for criticism in recent months.
The quasi-governmental entity with appointed civilian members — responsible for handing out millions of tax dollars each year to programs for substance use and mental health disorders — has drawn scrutiny from health leaders about whether it’s funding the right service providers and enacting the right quality controls. The board has been ridiculed for needing several attempts to draft a resolution declaring racism a public health crisis. And it was exposed for its policy promoting employee health and well-being with reimbursements for expenses like golf lessons and private dance instruction.
Most recently, board members bickered among themselves in email exchanges about whether they were doing enough to be transparent and raise public awareness of what the board does to help the community.
So, when an ADAMHS board – and Cuyahoga County’s is one of 50 in the state – displays this much dysfunction, does it suggest the system, itself, might be flawed? Should mental health and substance use disorders be treated through a centralized government department, rather than a quasi-independent board?
“I’m not going to say there aren’t boards who have had issues,” said Cheri Walter, the CEO of the Ohio Association of County Behavioral Health Authorities, a statewide organization that represents the interests of the county boards.
She maintains, however, that the local approach is best.
“It doesn’t make sense to throw the baby out with the bath water if it’s working in 95% of the system.”
Local control over local programs
Ohio’s Department of Mental Health and Addiction Services has oversight over the county ADAMHS boards, with legislation laying out their responsibilities and rules for how they should operate. Boards submit two-year comprehensive plans and file annual reports, detailing programs and their effectiveness.
But Ohio’s system for funding those programs that address mental health and substance use disorders deeply values local control. And involving the community in identifying its own needs and priorities is at the core of Ohio’s approach – an offshoot of the state’s belief in home rule, Walter said.
“We always, for years and years, had local involvement,” Walter said. “There was a belief that the care should be handled at the local level.”
That approach has its origins in the early 1960s, when President John Kennedy urged Congress to shift care of those with mental illness from exclusive state-level responsibility to a shared responsibility with local communities.
That’s especially important, Walter said, given the diversity from county to county – the differences between rural and urban areas, the wealth disparities, and the unique needs of multi-cultural populations.
It’s also important that the makeup of the board reflects the people it serves. By law, board members must live in the area that their board represents and should have personal knowledge of substance use disorders or mental illness.
At least one member must be a clinician involved in delivery of mental health services and another must be a clinician involved in the treatment of addiction issues. Two others must be people who are receiving or have received treatment from mental health services and addiction services. And two must have had a family member who received mental health or addiction services.
Most county boards have 18 members – 10 appointed by the county and eight appointed by the state.
Models differ from state to state
Ohio’s model matches most states’ approach to mental health and drug addiction services, said Jodi Manz, a project director for the National Academy of State Health Policy. It is a nonpartisan organization that supports the development of policies that promote and sustain healthy people and communities.
In larger states, such as California and Illinois, local boards also administer treatment services directly to clients.
Ohio law bans ADAMHS boards from providing those direct services. Instead, they contract with certified care providers for services to the public and often direct a hefty portion of local levy dollars collected for health and human services.
States with a centralized approach to mental health and addiction services tend to be smaller in population. But even those states often rely upon local or offices regional, staffed by state employees, to connect with communities, Manz said.
For example, South Carolina — with a population less than half of Ohio’s 11.78 million people — administers treatment for mental illnesses through the state’s Department of Mental Health. Those services, though, are provided through a statewide network of community treatment centers.
But substance abuse treatment is coordinated by a different state department through local agencies, Manz said.
Massachusetts, with less than 7 million people, has a centralized state Department of Mental Health Services, with 27 regional site offices and four continuing care centers. Like South Carolina, substance abuse in Massachusetts is covered by a different department.
In states where mental health and drug treatment programs are centralized at the state level, local providers are at the mercy of state spending — which can rise or fall from year to year, Walter said.
In Ohio, 50 separate boards administer programs in the state’s 88 counties. Because the boards are locally based, they can raise money through local taxes to target specific needs, Walter said.
Those needs can vary widely, too, depending on the makeup of a region, Manz said. Urban counties, for example, may tailor their substance abuse approaches toward addressing drugs, such as fentanyl, while more rural areas may wrestle with opioid addiction issues.
Finding housing for people receiving treatment can often be a bigger issue for smaller counties, simply due to a lack of adequate infrastructure, Manz said.
Proponents of the ADAMHS board model say the local approach is not only best for creative problem-solving around a community’s most vexing problems, but it also can lend itself to easier fundraising. Persuading voters to support local taxes for programs that change lives in their own neighborhood might be an easier sell than, say, appealing to a statehouse full of idealogues during budget season.
Equity and modernization
On the other hand, one argument for a centralized statewide approach is that it promotes funding equity from county to county, albeit at the mercy of state budget makers.
Walter acknowledged that some counties have greater ability to raise money than others, simply because they are a wealthier or larger community or have a broader tax base. In Cuyahoga County, more than $40 million of the ADAMHS Board’s nearly $87 million budget for 2022 will come from levy receipts.
State law requires a county to have at least 50,000 residents to have its own ADAMHS board. Nineteen of Ohio’s boards represent multi-county areas, sharing programs and fundraising efforts.
“Folks work together, particularly in some of the more rural areas,” Walter said.
Ohio hasn’t had a significant update of the section of the Ohio Revised Code that deals with mental health and substance abuse boards since the late 1980s, Walter said.
The code still includes some references to county mental health boards and addiction boards, both of which are long gone, Walter said.
A panel of people from across Ohio was convened by the state to gather feedback on possible changes. That panel is just beginning discussions, Walter said.
But while it will recommend changes to be considered, Walter said local control is engrained. She cannot imagine that the state would shift its focus from locally supported boards to a state centralized system in pursuit of equity.