Federal Harm Reduction Funding - Challenges and Recommendations
SIGN-ON LETTER
Challenges and recommendations around the rollout of the $30M Funding Stream for Harm Reduction under the American Rescue Act
Under the American Rescue Act section 2706, the Biden/Harris administration will be allocating $30 million “to support community-based overdose prevention programs, syringe services programs, and other harm reduction services.” This is a historic moment for the harm reduction movement in the United States. Never before has there been a federal funding stream specifically allocated to harm reduction purposes. Although this is a moment worth celebrating, because of its unprecedented nature we have many concerns with how the rollout will be conducted. At the root of our concerns is our belief that ALL harm reduction organizations should be able to access these funds. However, as it stands now, some organizations may be left behind.
Due to the novelty of this grant and after consultation with public health officials knowledgeable in this area, we can only speculate on how this process will work.
The statute provides that the funds will be distributed through SAMHSA in consultation with the Centers for Disease Control and Prevention (CDC). Typically, SAMHSA distributes funding for substance use programs through Single State Agencies (SSAs). SSAs are agencies established under SAMHSA that focus on behavioral health issues, predominantly substance use disorder treatment. However, SSAs are not necessarily familiar with harm reduction or syringe service programs (SSPs). In some states, the SSA is a separate agency from the state's Department of Health (DOH).
Under the current structure set up by the American Rescue Act, it is likely that the $30 million will be initially disbursed from SAMHSA to the SSAs, for either distribution to SSPs directly or passed through to the public health agency best placed to fund SSPs. Ideally, this would be a simple pass-through from the SSA to the state's public health agency, but this will not necessarily be the case. Either way, this structure poses a number of potential challenges.
In some states, SSAs may not be well-established or have clear fund distribution procedures for programs other than traditional substance use disorder services. Under the current structure, the SSAs have no obligation to pass the funds to the public health agencies most equipped to oversee harm reduction services. Although the legislation does state that the funds will be disbursed “in consultation” with the CDC, it is unclear what “consultation” actually entails, and therefore how much discretion or input the CDC will have in terms of distributing these funds.
It is promising however that the text of the legislation very specifically outlines the use of the funds under the grant. Section 2706(b)(2) provides that the funds will go “to support community-based overdose prevention programs, syringe services programs, and other harm reduction services.” Section 2706(b)(2) is more comprehensive, stating that the funds are to be used for “preventing and controlling the spread of infectious diseases and the consequences of such diseases for individuals with substance use disorder, distributing opioid overdose reversal medication to individuals at risk of overdose, connecting individuals at risk for, or with, a substance use disorder to overdose education, counseling, and health education, and encouraging such individuals to take steps to reduce the negative personal and public health impacts of substance use or misuse.” This deliberate framing leaves little room for interpretation or discretion to the individual agencies on how the funds will be spent. However, across numerous jurisdictions, differences in interpretation may nonetheless become problematic.
Another challenge that could arise is that to receive funding for SSPs, public health departments are required to file a “determination of need” with the CDC. This could potentially result in certain state agencies themselves being ineligible to receive funds to distribute to SSPs and other harm reduction programs. Because this funding has been granted as part of the American Rescue Act, this requirement would not apply unless SAMHSA specifically requires it. However, there can be no guarantee that SAMHSA will take this approach.
Finally, in order to quickly distribute funds to harm reduction organizations, there must be an existing relationship between the agency granting the funding and these organizations. It is feasible that in states without established relationships with SSPs, deserving organizations may not be readily identified.
Ultimately, the onus may fall on the organizations to apply for these funds. Many underground or very small harm reduction programs will be unable to apply for funding because they are operating in a legally grey situation, do not have the sufficient infrastructure, do not have grant writers, or have not obtained 501(c)(3) status. This could result in the very organizations that are arguably most deserving – and in most need of this funding – ultimately being left out.
One solution to circumvent these bureaucratic issues might be for SAMHSA to provide grants to larger grant-making organizations, such as North American Syringe Exchange Network (NASEN) or National Harm Reduction Coalition (NHRC), which can then distribute funds to smaller grassroots programs. In any event, significant technical assistance will be required to assist these organizations if they are to receive any funding at all from this grant. The National Harm Reduction TA Center is best positioned to provide this type of assistance.
The bottom line is that some organizations in certain states will be much more prepared to access the federal funding than others. At this point in time, many organizations will be stifled by legal, political, financial, and bureaucratic barriers. However, we believe that addressing these barriers is an opportunity to establish a relationship between SAMHSA and the harm reduction community, and educate leadership on the importance of low-barrier funding access.
The National Alliance of State & Territorial AIDS Directors (NASTAD), a non-profit association that represents public health officials who administer HIV and hepatitis programs in the US, is issuing a set of recommendations for SAMHSA, the individual state DOHs and SSAs, and SSPs / harm reduction programs. The recommendations will be made available by NASTAD in the coming days. We strongly support these recommendations and urge all organizations and entities involved in the rollout to work closely together to ensure that all harm reduction organizations in need are able to receive this vital funding.
In addition to the recommendations outlined by NASTAD, we would also like to emphasize the importance of the following:
We strongly recommend that the percentage of funds that can be used for administering the $30M grant should be limited to that amount that is most necessary to cover such costs. As a coalition of mostly grant-funded organizations, we are all too familiar with anywhere from 40-90% of our funding resources being lost to filing fees and administrative costs. By restricting how much funding may be spent on administration, the federal money will be better guaranteed to go towards the harm reduction organizations performing this important work.
We request that SAMHSA refrain from requiring public health departments to file a “determination of need” with the CDC, which as mentioned above could potentially result in certain state agencies being ineligible to receive funds to distribute to SSPs and other harm reduction programs. This requirement will not apply under the American Rescue Act unless SAMHSA specifically requires it. In order to broaden the field of potential agencies able to distribute these funds and cut down on the amount of “red tape” associated with their administration, SAMHSA should not require this filing.
We ask for the appointment of a dedicated “harm reduction liaison” on the federal level to work with SAMHSA and the CDC and monitor the funding roll out. The liaison will be able to troubleshoot any unforeseen issues, provide topical expertise, and advocate for the current needs of the harm reduction community.
In the future, we urge lawmakers to consider directing the CDC to administer and distribute funding for harm reduction (as opposed to SAMHSA), as the pathway and connection to SSPs and harm reduction networks would be much clearer and many of the above barriers would not exist.
This letter is intended to a “living document” that will be further developed and augmented as we learn more about the roll-out and distribution of this important grant.