ARTICLES

JPART 20:539–575

Temporary Crises and Priority Changes: The
Case of State Substance Abuse Systems
Michael R. Sosin
University of Chicago

Steven Rathgeb Smith
University of Washington

Timothy Hilton
Northern Michigan University

Lucy P. Jordan
University of St. Andrews

ABSTRACT
Many doubts have been expressed about the capacity of states to administer federally
supported social service programs. This article relies on institutional theory, punctuated
equilibrium theory, and evidence from two states to analyze the way states administer the
programs in times of ﬁscal crisis. The particular context is the ﬁscal crisis of the early 2000s in
substance abuse programs. The analysis suggest that, during the crisis, state administrative
authorities and the providers they funded refocused services on federal rather than local
priorities. The states and providers also further integrated substance abuse services with the
services of other programs and promoted managerial practices that seemed to loosen the
match between services and clients. The ﬁndings point to some of the ways in which the states’
capacities to respond to crises can be undermined by the national trend toward encouraging
state discretion. Findings also reveal challenges for state-level crisis management.

American social service programs are decentralized; even when states obtain sizeable (if not
necessarily sufﬁcient) resources from the federal government, they have considerable administrative discretion in implementing the service delivery systems in which the funds are spent.
For example, state administrative authorities and legislatures, here called state ‘‘actors,’’ decide whether to supplement federal service appropriations, how to mix multiple federal and
local funding streams, and what federally funded population groups to serve heavily. State
actors also mount a service system, selecting and regulating the agencies that deliver the
funded services. Those delivery agencies tend to be nongovernmental local nonproﬁt and
for-proﬁt service ‘‘providers’’ (Conlan 1984; Gutowski and Koshel 1982; Smith 2002, 2007).

This is a revised version of a article presented at the 2006 Annual Research Conference of the Association for Public
Policy Analysis and Management, Madison, Wisconsin. We deeply appreciate the comments provided on earlier
drafts of this article by Tom Gais, Stephen Page, and three anonymous reviewers. Address correspondenc to the
author at m-sosin@uchicago.edu.
doi:10.1093/jopart/mup022
Advance Access publication on August 27, 2009
ª The Author 2009. Published by Oxford University Press on behalf of the Journal of Public Administration Research
and Theory, Inc. All rights reserved. For permissions, please e-mail: journals.permissions@oxfordjournals.org

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Journal of Public Administration Research and Theory

Unfortunately, several policy makers, experts on services, and social welfare advocates express deep concerns about the ability of state actors to manage their social service
systems (Behn and Keating 2004; Finegold, Schardin, and Steinbach 2003; Lav 2007;
Provan and Milward 2001; Terry 2005). Some such concerns rest on the perception that
state actors tend to lack the administrative capacity to assure that service programs are of
high quality. The capacity problem is argued to arise because states often have small
administrative staffs and limited authority over providers. But another potentially vital
if less fully considered concern is that state actors may not always be able to fully defend
the state’s core service priorities. The priority problem may arise because service programs
tend to develop out of federal rather than state and local political demands and because
powerful constituencies that support states’ policies do not necessarily emerge.
The concern over priority setting has become particularly urgent since about the year
2000, when many states began to confront serious budget crises that necessitated sometimes drastic cutbacks in funding and services. It further gained urgency as the crises reemerged in dramatic form during the late 2000s (Behn and Keating 2004; Boyd 2003;
Finegold, Schardin, and Steinbach 2003; Holohan et al. 2003; Johnson 2002). State ofﬁcial
may struggle to decide which services to continue or cut during these crises since they must
balance (within the aforementioned limits) local conditions, political pressures, and the
constraints of federal funding. Their responses may not be consistent with any possible
expectation that decentralization unleashes local creativity or encourages the development
of priorities that are tailored to local patterns of need.
The current article empirically examines state and provider reactions to ﬁscal crises,
focusing on reactions in substance abuse service systems to the ﬁscal crisis of the early
2000s. Substance abuse service systems are of interest because they are relatively representative of publicly ﬁnanced programs. For example, the systems involve the typical, complicated ﬁnancing patterns by which states mix and match service funding from a federal
block grant, Medicaid, state funds, and various other sources. The block grant is like other
ﬁnancial mechanisms of its type; it places a cap (ceiling) on federal service expenditures,
mandates that states establish a central administrative authority and maintain certain service priorities (states must assure levels of drug services and services to women with children), but otherwise allows considerable state-level discretion. The systems are also typical
in heavily relying for service delivery on state-funded nonproﬁt and for-proﬁt local providers. The particular focus of the current work is the reaction to the crisis of two states,
Oregon and Illinois.
As shown below, and as is consistent with available theory, the analyses ﬁnd that the two
otherwise very different states responded similarly to the ﬁnancial crisis. In both, state service
system priorities were increasingly aligned with federal priorities and with the priorities of
other state and local public programs. Providers in each state also were increasingly organized
around funding sources rather than around clients. In essence, the study suggests that the
promise of decentralization diminished when the ﬁscal burden increased. As is argued below,
these ﬁndings have general implications for understanding the nature of publicly funded service systems and the roles in ﬁscal crises (contemporary or future) of state administrators.
Background

The ﬁscal crisis of the early 2000s largely occurred because of a stagnant national economy
and ﬂat or declining state tax revenues. It also arguably reﬂected several other factors. For

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Temporary Crises and Priority Changes

example, states were prompted to cut services in some areas because new federal mandates
spurred increased spending on education, health, and other activities. States also were under
pressure to respond to emerging concerns. One was the concern over the increased number
of children needing foster care. Another was the concern over the ramiﬁcations of the Temporary Assistance for Needy Families (TANF) welfare reforms, such as the new demands
for funding for work supports (child care, transportation costs) and related services. Although certain states modestly raised fees or taxes, some were affected by tax limitation
initiatives that greatly reduced their ability to quickly raise revenues to compensate for
budget shortfalls. In any case, many states had little choice but to react in crisis terms
to the economic problems of the early 2000s (Behn and Keating 2004; Finegold, Schardin,
and Steinbach 2003; Hevesi 2005; National Association of State Budget Ofﬁcers [NASBO]
2002, 2006; Reschovsky 2003; Western Rural Development Center [WRDC] 2003).
Existing literature provides few insights about how state priorities are affected by
a crisis. For example, a scattered if dated literature analyzes national responses to the welfare state crises of the 1970s (Flora and Heidenheimer 1982; Geiger 1978; Hirsch 1976;
O’Connor 1973; Offe 1984) but that literature does not at all focus on state governments.
Studies of the ﬁscal crisis of the early 2000s, itself, tend to describe the state declines
in revenue and expenditures but do not fully examine changes in priorities (Finegold,
Schardin, and Steinbach 2003; NASBO 2006; WRDC 2003). Nevertheless, the studies
of the welfare crisis are indirectly relevant in implying that state crises may regularly occur,
since there is a basic incompatibility between government spending and the demands of
a thriving private economy (Flora and Heidenheimer 1982; Geiger 1978; Hirsch 1976;
O’Connor 1973; Offe 1984).
Perhaps the most relevant studies for current purposes are the small set of works on
cutback management that were completed by Levine and his colleagues (Levine 1978,
1979; Levine, Rubin, and Wolohojian 1981). Focusing on state and local responses to
the resource scarcity stemming from the welfare state crisis, those works argue that local
governments have entered a period of ﬁscal austerity that inevitably means that there will
be long-term reductions in the role, inﬂuence, and size of local service systems. States must
respond to the reductions by either living with crises, forestalling change, or reducing
spending on low-priority services. Responses will vary with the state’s administrative
and political capacity (Levine, Rubin, and Wolohojian 1981).
Levine’s enormously inﬂuential work still has echoes in many analyses (Bartle 1996;
Behn 1980; Berne and Steifel 1993; Bowling and Burke 2006; Gold 1992; Poterba 1994).
Its most intriguing insight for the current article is its very brief and not fully investigated
suggestion that, when states cut back, they ration based on their priorities. For, an important
extension is that states may redeﬁne low and high priorities during crises. In fact, redefinition seems likely when considering that crises tend to alter the economic and political
environments that surround services. It is argued below that several existing studies (Berne
and Steifel 1993; Kimmich 1986)1 can be reinterpreted to provide tentative empirical
evidence that state priorities change when ﬁnancial problems emerge.
The current work contributes to the literature on crisis management by investigating
in-depth whether and how crises lead to changes in priorities in delivered services, client
1
The Reagan-era studies also explain the changes initiated by the Reagan Administration that still affect social
services, including the imposition of ﬁscal caps (spending limits) through the implementation of a major federal
vehicle for supporting services, and block grants (Cahill et al. 1994; Conla 1984).

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mixes, and managerial routines. It does so while considering issues that are not at all raised
in the previous, often dated studies on crisis management, including how states rearrange
spending across what are now commonly multiple funding streams, the manner in which
changes in state priorities work their way through the complex state administrative structures (Lynn 2002; Smith and Lipsky 1993; Sosin 1990), and the reaction of local service
providers to state actions (Alexander, Nank, and Stivers 1999; Bischoff and Reisch 2000;
Gronbjerg, Musselwhite, and Salamon 1984; Reisch and Sommerﬁeld 2003). Four speciﬁc
questions are addressed: how state priorities change due to a crisis, how provider priorities
then change, how managerial patterns change due to a crisis, and whether any uncovered
changes are temporary or permanent.
Theoretical Background

The four questions are addressed here with the aid of two general theories: institutional and
punctuated equilibrium theory. The sociological version of institutional theory is a basic
perspective on how the structure and behavior of organizations (corporations, nonproﬁt
providers, and others) operate in socially, culturally, and politically charged environments
(DiMaggio and Powell 1983; Meyer and Rowan 1977). It argues that, in such ‘‘institutional’’ environments, powerful people like state and federal ofﬁcials demand conformity
to process-related standards more than success on ultimate outcomes. The environments of
social service programs generally are highly institutionalized.
A key insight of institutional theory is that local organizations (like state governments)
often become ‘‘isomorphic’’ or similar to each other in structure or behavior. This occurs
because socially accepted ways of thinking or acting can spread across the national or even
international sphere. There are multiple types of isomorphism. Coercive or regulative isomorphism occurs when organizations respond to direct outside pressure (Scott 2001), such
as when state governments set priorities on the basis of federal incentives and mandates.
Normative and mimetic isomorphism occur when organizations conform to the culture,
such as when state governments borrow priorities from professionals (normative isomorphism) or from the priorities of the federal service systems (mimetic isomorphism, involving copying that which is popular).
Institutional theorists argue that crisis-like events (DiMaggio and Powell 1983;
Fligstein 1991; Greenwood and Hinings 1996; Meyer and Rowan 1977; Zucker 1987)
or other exogenous shocks can weaken the social or political support that is given to preexisting institutional standards (Greenwood and Hinings 1996; Ocasio 1999; Oliver 1991;
Rao 1998). When that occurs, ‘‘entrepreneurs’’ may seek out new standards (rules, norms,
etc.) that help regain that support (Ang and Cummings 1997; Hoffman and Ventressa 1999;
Ingram and Simons 1995; Suchman 1995; Swidler 1986). The theory also suggests that
a common way of regaining support is by locating and adopting available, socially valued
standards (Clemens and Cook 1999; Johansson 2003; Leblebici et al. 1991; Oliver 1991;
Rao 1998; Suchman 1995; Swidler 1986). Those standards then tend to spread. In other
words, crises are likely to result in widespread changes in standards as exempliﬁed by broad
changes in service priorities.
Punctuated equilibrium theory (Baumartner and Jones 1993) argues that ongoing investments of public ofﬁcials and service agencies in a given mix of services creates disincentives for change, in part because established state actors have many opportunities to
block proposed alterations (Pierson 2004). It also suggests that dramatic policy shifts can

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Temporary Crises and Priority Changes

occur when there are windows of opportunity (the potential for political acceptance) and
particularly committed policy entrepreneurs. But the constellations of interests that develop
subsequent to policy change can be self-reinforcing, producing political support for the new
approaches and thus inducing enduring change in the policy subsystem.
Institutional and punctuated equilibrium theories offer several similar insights, such
that policy change can occur when state actors or other entrepreneurs take advantage of
the uncertainty brought about by brief, crisis-related periods. But the current work
focuses more on the insights from institutional theory. This reﬂects that the interest
groups as described in punctuated equilibrium theory are not very inﬂuential in the states
examined here (provider associations do have moderate inﬂuence) but that pressures
from such institutions as the federal government are quite powerful. The work relies
on insights from punctuated equilibrium theory to consider whether priority changes
endure.
Theoretical Propositions

The preliminary insights provided by theory give rise to four theoretical propositions, each
of which speaks to one of the four research questions, and each of which is discussed below
in the detailed case study material from the two examined states.
PROPOSITION 1:

A crisis alters the state allocation of resources in ways that increase the
integration of priorities across levels of government and program areas.

Institutional theory suggests that alterations in standards tend to be brought about in
crisis-like periods, where the social acceptance of the old standards and routines wanes and
new standards spread in ways described above. It follows from the theory that, when state
revenues in substance abuse services decline, established state priorities will lose social
support (the priorities are no longer helpful in obtaining revenues) and state actors will
search for new standards. A likely possibility is that their search will lead them to standards
emanating from the federal government. For example, state actors are likely to seek out
federal funds and thus to alter service priorities to meet federal mandates (regulative isomorphism). Further, since the aforementioned issues of small staffs, limited authority, and
weak constituencies tend to limit state actors’ capacity to develop new priorities on their
own, the actors may believe that they will be best able to protect services by mobilizing
state support around priorities that are popularized by the federal government (cognitive
and normative isomorphism), even when no new federal revenues are thereby obtained. (As
in turns out, the priorities of TANF proved particularly useful.) Financing or social support
also may be garnered by treating populations served by other, popular state and local programs. It further follows from theory that reductions will be made in services that are not
politically and ﬁnancially supported by the federal government nor by other state and local
programs (Greenwood, Suddaby and Hinings 2002; Leblebici et al. 1991; Oliver 1991; Rao
1998; Zucker 1987).
PROPOSITION 2:

During the crisis, providers alter the mix of services in ways that increase
the integration of priorities across levels of government and program
areas.

A straight-forward application of the notion of regulative isomorphism is that substance
abuse providers will alter their priorities when the state changes the populations or services

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Journal of Public Administration Research and Theory

that it heavily funds;2 providers tend to be affected by changes in state regulations. But a subtle application of the theory suggests that priority shifts may also occur because providers
who experience a crisis turn to local governments to fund services, and the new funding
sources tend to rely on state and national trends to build political support for providing substance abuse services (normative isomorphism). The theory also suggests that providers are
likely to widen their search for funds to other local service programs that have community
support. The providers thereby increase integration between the substance abuse and other
local service programs. For example, it is argued below that many substance abuse providers
obtained funding from well-established state or local mental health and correction departments, thereby focusing (some) services on mentally ill individuals and ex-prisoners.
PROPOSITION 3:

A crisis promotes managerial changes that increase provider tendencies
to select and process clients on the basis of the clients’ contribution to the
revenue stream.

Cognitive isomorphism (DiMaggio and Powell 1983) describes how, in an institutional environment, structural or behavioral patterns can spread. In the current case, the
spread of the state’s crisis-related administrative reforms is likely to alter provider-level
management practices. In typical systems, state actors bring about this alteration in at least
two ways: by specifying the clients and problems that are eligible for state reimbursement
and by otherwise increasing the providers’ incentives to serve high-priority groups and
services. In response, the providers are compelled (regulative isomorphism) or learn (cognitive isomorphism) to marry service delivery to calculations about available funding.3
PROPOSITION 4: Alterations that occur during a crisis continue beyond the end of the crisis.

Punctuated equilibrium theory suggests that, as interest groups mobilize around the
new priorities, the alterations brought about by a crisis help give rise to a new equilibrium
that does not involve a return to the previous status quo. Institutional theory might add that
the new approaches become taken for granted, that is, seen as the norm.
The patterns suggested above imply that ﬁnancial downturns threaten the integrity of
service systems. Policies may come to lack continuity with the past since they are adjusted
for ﬁnancial rather than service reasons. Providers can become increasingly oriented toward ﬁscal rather than service demands. Moreover, the sometimes problematic changes
that occur in response to a crisis can last for a long time after the crisis is over. The discussion and conclusion sections return to such implications.
METHODS

The two states in which reactions to a crisis are analyzed, Illinois and Oregon, were selected
in part for their geographic diversity, in part for convenience and in part because their
2
Service priorities change because funding agencies control the population groups and services that providers
deliver, at least in a general way (Meyer and Rowan 1977; Tolbert 1985). Of course, control devices may imperfectly
direct provider behavior (Agranoff and McGuire 1998; Brodkin 2005; Fredrickson and London 2000; Milward 1993;
Milward and Provan 2000; Mirabella 2001; Provan and Milward 1999; Romzek and Johnston 2005; Van Slyke 2006).
As noted below, provider behaviors may also change in ways that state leaders do not anticipate.
3
The administrative system adopted by states is not like that typically described by New Public Management
literature, in which providers compete and states divvy up revenue on the basis of performance rather than the
categories of clients served (Alexander 2000; Brodkin 2005; Hood 1991; Kettl 1997; Terry 2005).

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Temporary Crises and Priority Changes

substance abuse systems were affected by state ﬁscal crises. As argued below, the two
also offer substantial variation in organization and in the nature of the ﬁnancial crisis of
the early 2000s.
Organization

Oregon integrates its substance abuse and health programs and has a relatively weak-state
substance abuse authority. The ofﬁcial state authority for substance abuse services in Oregon,
now called the Addiction and Mental Health Division (AMHD), is of the major units
organized under the state service umbrella agency (Department of Human Services). That
division directly funds providers of residential and inpatient treatment. The state’s outpatient
substance abuse and mental health services instead are provided under a general health care
program for the poor that is administered by several managed care ﬁrms. Oregon providers,
who often specialize in both mental health and substance abuse services, frequently receive
revenues from AMHD and several other state and local public sources.
In contrast, Illinois has a relatively integrated system. Most resources for substance
abuse services to the poor stem from one Illinois state authority, the Division of Alcohol
and Substance Abuse (DASA). This is a separate unit that is directly under the state service
umbrella agency. DASA organizes and manages almost all the state’s substance abuse services. Providers receive high proportions of their resources through DASA, although some
of the revenues originally emanate from other units of government. Providers tend to only
specialize in substance abuse services and obtain limited funding from local public sources.
Wealthy clients rarely are served by either state’s providers.
Budget Crisis

The budget crisis was precipitous in Oregon—it occurred in a very short time frame as the
state’s high technology–related industries sagged and tax revenues unexpectedly declined.
Personal income tax collections, which comprise close to 90% of state revenues, were an
inﬂation-adjusted4 $8.2 billion for the 1999–2001 biennium. The inﬂation-adjusted estimate for revenues collected in the 2001–03 period was $7.3 billion, even if the adopted
2003–05 budget assumed collections of $8.5 billion (inﬂation adjusted). Corporate taxes
were estimated to be cut in half (a loss of about $400 million) between 1999 and 2001 and to
then further decline. The declines in 2001–03 came after years of robust expansion
(Oberlander 2006). Public expenditures on substance abuse services thus dropped substantially, from $50.9 million in the 2001–03 biennium to $35.1 million in 2003–05 (inﬂation
adjusted). Expenditures slightly rebounded to $38.6 million in 2005–07 (Ofﬁce of Mental
Health and Addiction Services 2006).
In contrast, Illinois is characterized by a pattern recognized by Levine (1978) in which
revenues essentially cease to grow over time. Because the economy slowed in the late
1990s and ﬁrst half of the 2000s, tax revenues from state sources remained almost ﬂat.
These revenues were about $21 billion in 1998 but only $19.5 billion (inﬂation adjusted)
in 2003. They reached a temporary maximum of $22.7 billion in 2000. (Revenues grew in
2005 to about $23.4 billion, inﬂation adjusted.) Even if routine increases in funding from
the federal government helped the revenue picture, service demands increased beyond
funding due to inﬂation, population growth, and other growing needs and demands.
4

Budget ﬁgures are converted to 1998 dollars. Midpoints are used to convert budget ﬁgures that cover multiple years.

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Journal of Public Administration Research and Theory

From 1998 to 2001, Illinois state budgets for substance abuse treatment moved
steadily upward slightly higher than the rate of inﬂation, growing from about $167 million
to $196 million (inﬂation adjusted). Even so, providers felt ﬁnancially limited since the
state began to monitor them heavily, refusing to pay for clients not deemed eligible for
services. The crisis as deﬁned here fully developed later on, when the budget later became
almost fully ﬂat; Illinois’ substance abuse budget was an inﬂation-adjusted $196 million in
2001 and $197 million in 2004. (Expenditures run a year behind the budget.) All in all,
given that the organization of services and the nature of the crisis differ widely across
the two states, any similar patterns of change that are discovered have the potential to generalize across many states.
State-Level Data Collection

The analysis of responses to the crisis partly relies on focused interviews conducted with
state ofﬁcials in Oregon and Illinois. Interviewees included each state’s chief administrator
of substance abuse services (the formal position varied), the central experts in reporting and
tracking services (as determined by the chief administrator or other state contacts), the
prime state ofﬁce budget experts, and representatives from the core lobbying groups
(as suggested by interviewed providers).
The focused interview instrument was primarily developed on the basis of the insights
from institutional theory as outlined above. The instrument (see Appendix 1) provides
a range of questions on the nature of the crisis (e.g., how tight revenue is and whether
the situation is deﬁned as a crisis), the policy response (e.g., whether state ofﬁcials changed
funding patterns or reimbursement for types of services as suggested by the hypotheses),
the rationale for that response (e.g., whether the ofﬁcials took into account the availability
of revenues), and the reaction of providers to state changes (e.g., perceptions about changes
in provider services). A separate instrument directly asks providers about change. The statelevel instrument also includes questions on the operation and ﬁnancing of the substance
abuse system. The state analysis also relies on various written materials concerning state
budgets and other matters discussed below.
Provider Study

The analysis also makes use of detailed interview data collected from 26 providers in the
two states. The providers in Oregon are a subset of non–hospital-based licensed substance
abuse units. One comprehensive state list identiﬁes the providers. Licensed providers that
obtain government ﬁnancing are a large proportion of all substance abuse providers in the
examined local areas. The Illinois providers are a subset of the nonhospital entities speciﬁcally licensed to be eligible for (and to usually receive) state substance abuse funds. A
state Web site contains a complete list of licensed agencies.
Relying on the detail available from the state lists, providers were purposively selected
on the basis of four criteria: size, service, location, and diversity in coverage. With respect
to size, the sample was selected to represent both providers who have less than two treatment sites and those who have more than two treatment sites. Multisite (as well as multiservice) providers dominate the sample because they also dominate service delivery. With
respect to service, providers were selected on the basis of whether they delivered outpatient
services not attached to inpatient programs (nearly all providers deliver some outpatient

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Temporary Crises and Priority Changes

services), detoxiﬁcation services (short-term services offered to clients to help them stop
drinking or taking drugs), residential services, and recovery home services (drug and alcohol free residences that do not necessarily furnish ongoing treatment).5 With respect
to location, providers were selected from both the major city and smaller urban areas.
In Oregon, selected providers are in the Portland (heavily emphasized) and Eugene areas.
In Illinois, providers are in Chicago (heavily emphasized) and the surrounding, sometimes
suburban counties—it was not possible to ﬁnd sufﬁcient providers in any one surrounding
county. Finally, when choices were possible (largely in Chicago), the sample was selected
to maximize local geographic and racial diversity.
Ofﬁcials were interviewed in 11 providers in Oregon6 and 15 in Illinois.7 Few providers formally refused to be interviewed (only two in Illinois, for example), but some
failed to ﬁnalize appointments, apparently due to hesitation about discussing ﬁscal matters.
One research team of two people collected the data pertaining to each state. Interviews were
routinely conducted with a senior agency ofﬁcial, generally the one designed as the ofﬁcial
contact with the state. In large agencies and when possible, an interview was also conducted
with a clinical supervisor heading the unit or service under consideration. In small agencies,
a small group of ofﬁcials often was interviewed at one session.
The detailed provider-level focused interview schedule (Appendix 2) was developed
from the theory described above and also from reviewing the literature on likely ways in
which providers cutback or ration (Lipsky 1981) services. It includes questions on such
matters as the funding, organization, and delivery of services; changes in provider funding;
and changes in organizational structure, stafﬁng, services, and relations with the state. It
focuses on changes that occurred between the start of the ﬁscal crisis and the time of data
collection. Most interviews were completed during 2006. The Appendix provides the
interview schedules.

Coding and Analysis

The analyses use the interview notes and also formally coded data from the provider interviews. The coded data cover the services delivered at each provider; the administrative,
ﬁscal, and strategic reaction to the crisis of the providers; and the overall ﬁscal health
of the providers. Consistency in coding between sites was obtained through discussions
and recoding.
5
Given the organization of the providers, many deliver more than one type of services. Analyses focus as much as
possible on the chosen service, but this is not possible when considering small providers, who do not highly
differentiate management across services.
6
Nine of these providers are located in the greater Portland area; one is in the Eugene area and another agency is near
the Paciﬁc coast. In all, 8 of the 11 are nonproﬁt agencies, 2 are for-proﬁt, and 1 is part of a tribal government. Two
providers have single-site operations. Four providers only deliver outpatient services (all other providers also deliver
outpatient services). Of the remaining seven providers, all deliver residential services, four deliver detoxiﬁcation
services, and four include recovery housing or homes. Six of the interviewed providers in Oregon (and only one in
Illinois) also deliver mental health services and, thus, are what are called behavioral health generalists.
7
Eight operate in Chicago, four operate only in the other examined communities, and three operate both in and
outside Chicago. Two are for-proﬁts and one is a unit of government. Five providers have a single service delivery site,
one operates in two sites, and the remaining providers have more than two sites. Seven are only outpatient providers,
one of which primarily offers methadone services. Two are recovery homes. The other six were selected to cover either
detoxiﬁcation or residential services, although most provide three or all four types of services (a small number of large
providers deliver most of the state supported detoxiﬁcation and residential services).

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Table 1
Summary of Results Regarding Proposition 1

Revenue
Change

State

General Change
in Priorities

Movements Toward
Federal Priorities

Movements Toward
Priorities of
State Institutions

None located
Eliminates coverage
Eliminate program
Oregon Precipitous:
for nonfamilies;
category (outpatient);
maximum loss
co-payments may
trim other programs
of $15.8 million
disadvantage
nonfamilies without
federal income
support
Increased funding for Special programs target
Illinois Gradual: slow lost Movement toward
child welfare clients,
Medicaid clients
special revenue
to inﬂation as
corrections clients
(families); arguably,
programs
revenues near
increased funding
constant,
for child welfare–
1998–2004
related services

RESULTS

Below results are organized by research issue and state. The basic results also are reported
in simpliﬁed form in Tables 1 and 2.
Issue 1: State System Priority Changes

The ﬁndings about the shifts in services in Oregon clearly illustrate part of the ﬁrst proposition by suggesting that crisis-related changes quite strongly increased integration
Table 2
Summary of Results Regarding Propositions 2, 3, and 4

State

Movement Toward
Federal Priorities
(Proposition 2)

Movement Toward
Priorities of State
Institutions
(Proposition 2)

Managing Finances
over Clients
(Proposition 3)

Retaining Changes
when Funding
Conditions Alter
(Proposition 4)

Providers turn toward Waitlist management; Programs continue to
Oregon Large loss in
serve women and
closing of programs
corrections, child
outpatient services
children even when
for single adults;
welfare, court
to single men
some funding returns
approaches
services, mental
(records verify)
for programs for
toward searching
health services
single men; strategic
for large outside
searches for revenues
clients; redeﬁning
continue
services as mental
health issues
Use of new funding
Illinois Reduction in services Providers turn toward Provider retention
categories to set
child welfare and
policies; wait- list
to white male
service priorities
corrections clients
management; search
alcoholics
ensures that the
for treatment
(records verify);
traditional priorities
efﬁciency (group
increase in drug
do not return as
or individual
services (records
funding increases;
counseling
verify)
strategic searches
models);
continue

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Temporary Crises and Priority Changes

between state and federal policies. The ﬁndings from Illinois fully support the proposition
by showing that the allocation of revenues changed in ways that gradually altered the mix of
services and clients toward both federal priorities and the priorities of other Illinois service
programs.
Oregon

As Table 1 suggests, the most dramatic priority change in Oregon occurred in outpatient
substance abuse services; eligibility for services was eliminated for single poor clients and
others who were not covered by federal income maintenance programs, but eligibility for
services was retained for poor families and others who the federal government does cover.
The Oregon reforms show an interplay between state and federal priorities that is consistent with the ﬁrst theoretical proposition. They particularly highlight the role in change
of institutional rules attached to revenue streams, thus illustrating the workings of regulative isomorphism. As the interview and written data suggest, Oregon actors ﬁrst proposed
to respond to the ﬁscal crisis by cutting speciﬁc services from Medicaid. But the federal
government refused to allow what was viewed as the creation of inequity in coverage across
medical conditions (Oberlander 2006). Therefore, state actors needed to eliminate entire
population groups in order to balance the budget. For obvious (regulatory) reasons, the
actors chose to only continue to provide substance abuse services for women with children
and other groups whose coverage was mandated under Medicaid. To be speciﬁc, the state
continued the Oregon Health Plan (OHP) Plus program, a program that served people typically eligible for Medicaid (children, pregnant women, parents who receive TANF, and
elderly and disabled people). It eliminated entries into the OHP Standard program, a program that served adults without dependent children and others not usually covered under
Medicaid (Mann and Artiga 2004; Oberlander 2006). Between January 2003 and January
2006, estimated enrollment in the OHP Standard program declined from 104,000 to 24,000
(Oberlander 2006). The crisis almost certainly is responsible for the changed state policies;
the Standard program was expanded in 2002 but was almost immediately cut as the crisis
emerged.
Across-the-board, albeit less extreme cuts also took place in response to the crisis.
These cuts did not obviously involve invidious choices but still affected single adults
more than families, again mirroring federal priorities. To be speciﬁc, legislation passed
in February of 2003 added a co-payment for each client treatment session. Families would
be more likely to be able to pay than poor single individuals because they could receive
personal ﬁnancial support from federal welfare programs. (Programs receiving General
Fund money also have not received a rate increase since 2000; Oregon Health Services
Commission 2004, 2007) Residential service expenditures were reduced by $1.5 million
(in 1998 dollars).
Illinois

The changes in Illinois occurred because state revenues from the traditional substance
abuse service stream grew more slowly (often not at all) than revenues from new sources,
whereas the new sources tended to fund services that covered groups that were federal
priorities or priorities of service systems other than the substance abuse system. The pattern
of change partly occurred due to regulative isomorphism, in that Illinois actors turned to
federal funding streams and thus covered federally mandated groups. But the pattern also
reﬂected normative isomorphism, in that state actors were able to attract political support

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to cover TANF recipients and other groups whose visibility was increased by federal
reforms.
Much of the pattern of change is revealed by considering a key 2005 reform by which
Medicaid funding for substance abuse services in Illinois was increased by $10 million per
year. On the one hand, the new Medicaid revenues were used to provide services to such
federal priority groups as disabled individuals and single mothers. That reﬂects the regulations; the Illinois Medicaid program only covers federally mandated clients. On the other
hand, legislators were in part convinced to so increase Medicaid funding (states pay part of
the costs) by (normative) pressure to provide services to welfare families. Those pressures
arose from the state’s attempt to implement federal TANF reforms.
The Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (US
Public Law 104-193) signaled a new national approach to dealing with family poverty, one
that heavily focused on work in the reformed income maintenance program, TANF. A speciﬁcally relevant national pressure was the claim that substance abuse issues were barriers
to the work effort of the TANF population (Pollack et al. 2002). Accordingly, state ofﬁcials
who stressed providing substance abuse services to women with children could justify their
efforts as feeding into the national movement to improve the work readiness of poor, single
heads of families. Indeed, state ofﬁcials informed us that the Medicaid increase was at least
partly adopted as a way of subsidizing substance abuse services during a crisis, riding the
political prominence of TANF as well as making use of the available, matching, Medicaid
funds.
Similarly, as the hypothesis suggests, federal and local (normative) pressures spurred
an integration of substance abuse and child welfare services. This was possible because
child welfare services were being reformed to stress providing substance abuse or other
services that might help reform family heads. The integration helped to stabilize substance
abuse revenues. Beginning in the late 1990s, DASA obtained from the legislature ‘‘DCFS
money’’ (Department of Children and Family Services funding) to treat the substance abuse
problems of parents who were referred from the child abuse and neglect system. The new
money was provided in response to a court decree mandating improved service in the child
welfare system and the national concerns about the substance abuse problems in families
served by that system. Substance abuse providers also sometimes received substance abuse
service funds from the state Department of Corrections (DOC). Although it is not clear
when DOC money ﬁrst became available, it is clear that the funding increased during
the crisis era when inmates were released from a newly closed correctional facility.
Issue 2: Provider Responses

As Table 2 suggests and as the second proposition predicts, the substance abuse services
actually delivered during the crisis by providers in both states were also increasingly focused
on the clients or services that were priorities of units of government other than the substance
abuse authority. This occurred due to both what theory calls regulative and normative isomorphism; providers changed priorities in order to obtain state funding and they also adopted the priorities of the revenue-providing units that they sought out on their own.
Oregon

In Oregon, although a temporary income tax, the I-Tax, softened ﬁnancial problems in the
metropolitan Portland area, the ﬁscal crisis in Oregon resulted in signiﬁcant immediate job

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loss for treatment staff in the providers, particularly in outpatient programs. One respondent
estimates that over 600 treatment professionals in the state lost their jobs. The ﬁscal effect is
illustrated by a provider outside Portland that reported losing $2 million out of a $6 million
budget.
One major provider response to such a precipitous revenue loss was to drop outpatient
programs. In all, 4 of the 11 interviewed providers report that they either cut all their programs at some of their sites or abolished one or more treatment program within a given site.
The provider noted above, which had seven programs in 2002, reportedly cut out ﬁve of
them. A provider with ﬁve programs cut out three. In an obvious example of regulative
isomorphism, three of the four providers reported dropping the programs that were targeted
at the groups that the state no longer funded. As one provider’s executive noted, although
a revenue decline could create operational problems, the state cut was so dramatic that it
was necessary to immediately ‘‘bite the bullet’’ by dropping programs rather than evenly
rationing the cuts. He credited a management information system for his ability to target
cuts toward programs serving clients who were not ﬁnancially viable because they would
no longer be funded by the state, like OHP Standard-eligible clients. This provider like
others also cut out alcohol rather than drug abuse services, reasoning that OHP Standard
clients often suffered from alcohol abuse. Ofﬁcials subjectively felt that cuts particularly
affected ‘‘male white alcoholics,’’ often older, single, homeless, and near homeless men.
The relative size of the programs of at least two providers that did not drop programs
changed. Both reduced services to the groups described above. One agency in Eugene
reported reducing the size of the men’s outpatient program from 50 to 10 people; a Portland
area agency eliminated 50 clients who were supported by ‘‘indigent funds.’’ State funding
changes spurred these choices about what to cut.
A second change, one which also reﬂects how providers conform to ﬁnancial incentives (regulative isomorphism), was that 5 of 11 interviewed substance abuse providers in
Oregon came to serve clients who were of interest to local authorities who would fund
substance abuse services. These authorities tended to provide funding for clients out of
the funding pools of other popular local programs, like the child welfare program. Accordingly, there was an integration of the substance abuse and other programs. For example, one
provider reported placing staff on location to obtain referrals related to substance abuse
services from health clinics, child welfare agencies, and the like, locations where clients
come attached to health, child welfare, and other government funding streams. Another
nonproﬁt provider’s manager reported looking locally for revenue sources and ﬁnally making a contract with one speciﬁc judge. The provider was then able to increase the pool of
court referrals for driving under the inﬂuence (DUI), serving about 200 clients from the
judge’s court in the 18 months in which the referral link operated. Although Portland’s
justice system funded about 12%, DUI clients otherwise paid for their treatment. Another
manager reports pursing contracts with corrections and hospitals.8
Studied Oregon providers who are behavioral health (mental health and substance
abuse) generalists tend to suggest that mental health treatment is an important component
of interventions with adults with substance abuse problems. The administrators of each
8
A number of providers report expanding services speciﬁcally funded by an Oregon trend toward using and funding
evidence-based practices, including services to methamphetamine-addicted clients. Funding followed federal block
grant dictates that states encourage some evidence-based practices. Providers report that they could obtain special state
funds by focusing on these practices.

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such provider also discovered that it was strategically advantageous to have access to funding from mental health pools. Of these, ﬁve providers succeeded in attracting the funding.
For example, the leaders of a small agency report adding the requirement that staff members have dual (mental health and substance abuse) certiﬁcation. The director said that this
was accomplished to allow the provider to draw funding (when ﬁnancially beneﬁcial) from
either the mental health or substance abuse revenue stream. Another provider found a special fee for service mechanism that could be used to provide new, combined mental health
and substance abuse services. One director even suggested that he was working to diversify
out of substance abuse altogether by expanding into strategic partnerships with child welfare agencies and with agencies in the criminal justice system, thus turning to apparently
relatively stable funding sources. In contrast, providers reported only mildly increased
focus on private insurance clients. State-funded providers are not well positioned to provide
the high-end services private pay clients expect. Managed care imposes strict ﬁnancial
limits to insurance coverage.
A report by RMC Research Corporation (Gabriel and Deck 2004), which tracked total
admissions for 2003 in publicly funded substance abuse treatment (not just admissions of
the clients funded by the state), provides statistical evidence of the relative decrease in
services for nonfederally funded clients. The report shows an estimated 20% decline in
admissions to substance abuse programs during 2003.9 It also notes that the decline
was 41% for OHP Plus clients and a larger, 75% for OHP Standard clients (those not federally funded). The report speciﬁcally notes that clients who cannot afford the co-payment,
and clients in the single, heavily male non-insured population, were hardest hit.
Illinois

In Illinois, since providers receive substantial funding from the central state authority, the
providers’ priorities changed in obvious ways with the changes in state priorities (regulative
isomorphism). As Table 2 suggests, the interviewed providers increased services to clients
whose state and local support levels increased: the TANF clients and clients served by other
state programs. The state divides its payments to providers into several separate programs;
changes occurred due to the relative movement in the size (provider funding cap) of the
programs.
Ofﬁcials in 10 of the 15 studied providers pointed out that their agency obtained ﬂat or
reduced funding between 2001 and 2005 from the so-called ‘‘global’’ funding program. The
global program can serve any poor person in need. In contrast, ofﬁcials in eight providers
report that support during the same period increased for the state programs that funded the
Medicaid, DCFS, DOC, and other special populations. Providers naturally increased services to the clients that the specialized programs funded and reduced the relative focus on
single men and others who were supported by the global program. (Perhaps three providers
found signiﬁcant support elsewhere, turning to local governments, foundations, or state
agencies that handle gambling addictions.)10
9
By another estimate, Oregon served 71% of persons needing publicly funded substance abuse treatment in 2000–01
and only 53% in 2004–05 (Governor’s Council on Alcohol and Drug Abuse Programs 2006).
10
To be sure, the global-related revenues of four providers reportedly substantially increased. The reported increases
occurred among large, well-established providers that focused on services that the state wished to stress, like recovery
home services, and among those in suburban areas where populations were quickly growing; crisis management
increased relative funding of particular services and geographic areas. The reported decline occurred in a residential
agency.

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Temporary Crises and Priority Changes

A trend that is indirectly tied to priority changes was the relative growth of large over
small providers. Ofﬁcials in six large providers reported that their agencies received reallocated revenues during some crisis-era years. The reallocated revenues arose when other providers underspent. The tie to priorities is that the larger providers generally serve women with
children, pregnant women, and such other DASA priorities as clients with heroin addictions
or HIV/AIDS. It also reﬂects that the larger providers can easily increase services to clients in
the high-priority groups. For example, the director of a large provider located near a concentration of poor families suggests that his operation is so large that he ﬁnds it ‘‘no problem’’ to
expand the client pool to obtain the left-over revenues. With minimal added costs, he increases recruitment, lengthens the length of the line waiting for methadone maintenance,
and uses existing workers to provide to new clients the brief, mandated counseling sessions.
Available client-level data in Illinois, which do not provide detail on all trends, again
conﬁrm major points from the interviews. The client-level data stem from DASA reports on
service ‘‘episodes,’’ which in turn are compiled from provider reimbursement forms.11 The
data in the reports reveal that funded alcohol services episodes remained stable over the
reporting years, but that a dramatic decline was evident in most crisis years in services
delivered to a category speciﬁcally labeled as ‘‘white male alcoholics.’’ The decline
was from 33,451 service episodes in 2000 to 19,895 in 2005. Similar to the situation in
Oregon, white male alcoholics in Illinois are often part of the older, homeless clientele
traditionally served by DASA but rarely covered by the Medicaid or DCFS programs
(Sosin, Colson, and Grossman 1988). The data also point to a trend between 2000 and
2004 (2005 data were unavailable) toward delivering drug-related services. The number
of reported heroin-related service episodes increased across these years from 19,854 to
45,334; the number of episodes pertaining to methamphetamine increased from 740 to
5,253. Service episodes related to marijuana increased from 20,773 to 32,901 (probably
largely due to increases in services to youth). In fact, although there was an increase in
episodes between 2000 and 2004, it is fully accounted for by the reported change in drug
services. The patterns mirror the stress on TANF and also the priorities of federal block
grants, which place relatively high emphasis on services to those with HIV/AIDs or drug
abuse problems and to women, especially women with children.
Issue 3: Fundamental Administrative Shifts

As reported in the third column of Table 2, and as suggested by proposition 3, there is
substantial evidence that providers responded to the crisis by increasingly managing ﬁnances rather than clients. In Oregon, ﬁnancial incentives had generally spurred a process of
that might be called cognitive isomorphism: providers became accustomed to planning
programs (and thus selecting clients) on the basis of ﬁnancial factors. The crisis intensiﬁed
use of these planning strategies. In Illinois, surprisingly similar changes occurred in response to intricate changes in state management practices.
Oregon

The Oregon public outpatient substance abuse service system is incentive based; providers
are reimbursed for each treatment session that they deliver to eligible clients. As the
Reports for some years were published and others were made available to the research team. These reports are
limited. They tally service episodes (the relatively continuous period in which a given agency served a given client) and
not clients, run several years behind the budgets, and are sometimes incomplete.

11

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Journal of Public Administration Research and Theory

incentives changed, providers usually came to adopt a type of incentive reasoning whereby
they regularly sought efﬁcient approaches of obtaining reimbursement. During the crisis,
providers used that reasoning approach to seek out efﬁcient ways of obtaining reimbursements from sources outside the normal substance abuse system, thus selecting clients and
services according to available funding.
The representatives of six out of the nine studied Oregon nonproﬁt providers describe
an increased focus during the crisis on securing large contracts from a small number of
outside entities. The representatives point out that the costs of handling each contract (paperwork, recruiting clients, and the like) can be born more easily in this way. As mentioned
above, interviewees also reported becoming increasingly entrepreneurial in searching for
funding opportunities, developing service opportunities when considering the availability
of funding in mental health, child welfare, and elsewhere. Several Oregon providers also
report adopting ‘‘waitlist management’’ practices of the type more fully described when
discussing reforms in Illinois, where clients without stable funding experience service
delays. To take one example, in 2006, poor single clients with alcohol problems referred
to the county-subcontracted treatment providers in the Eugene area were only served after
pregnant women, women with children, intravenous drug users, and other ﬁscally
supported populations (Lane County Health and Human Services 2006).
Illinois

In Illinois, state regulations spurred providers to deliver services according to the amount of
funds available from each discrete program offered by the state (like the DCFS program).
The interview data suggest that the balancing act eventually led to a new, general way of
thinking about clients, especially among larger providers. One trend is that larger providers
offering multiple services report responding to the crisis by using funding levels to determine the mix of outpatient, inpatient, residential, and recovery home services. For example,
an ofﬁcial in one large provider noted that state ﬁnancial reimbursement levels for recovery
homes, while low in absolute terms, actually were high when measured against the level of
services that the state mandates. As money became tight in the crisis, the provider added
recovery home beds. The provider reduced emphasis on residential treatment, a service that
for years suffered from fully stagnant reimbursement rates. The relative reimbursement rates
may have reﬂected the state’s interest in increasing the use of recovery homes (DASA used
a special federal grant to expand the use of the homes). Another provider reports increasing
and decreasing outpatient treatment staff in concert with monthly caseloads and residential
care costs overruns. Nevertheless, the most commonly reported adjustments in Illinois involved managing clients within a treatment program according to funding category. These
adjustments can only be explained by detailing the state’s reimbursement system.
Illinois providers are reimbursed by service episode. For example, they are reimbursed
for hours of services of a given kind of outpatient treatment and for days of services of
a given kind of residential treatment or recovery home services. As noted above, the reimbursement rates were frozen from 2000 to 2005 (when the reimbursement rate for all
services was ﬁnally increased by three percent). As a major lobbying association reported to
the research staff, the frozen rates led to a reduction of support in real dollar terms of over
30%. Providers also reported that expenses rose due to a new state mandate to hire certiﬁed
and thus relatively costly, workers.
Ofﬁcials in all but three analyzed providers reported compensating for ﬁscal problems
by seeking ways of billing the state for more client episodes per staff member. (The

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Temporary Crises and Priority Changes

exceptions are a growing provider of outpatient drug services and two providers of drug
treatment service who regularly managed to obtain money from the state at the end of most
years.) For example, ofﬁcials in four providers reported placing increased emphasis on
client retention. Each of these providers learned that they use worker hours more efﬁciently
when client attrition is low and gaps in billable hours are minimized. The providers tried to
increase retention in many ways: by stressing case management and support services
(which DASA has recently decided are routinely billable in an innovative administrative
move clearly designed with the ﬁnancial crisis in mind), targeting clients most ready to
beneﬁt from (and remain in) treatment, and scheduling treatment sessions to coincide with
other client activities (e.g., methadone pickup).
Although retention helps clients in theory, the managerial practices that increase retention also demonstrate the strategy of managing clients as revenue sources. One interviewed manager reported receiving accolades from his headquarters by aggressively
increasing the length of stay in the treatment program he administered. He listed a host
of policies he implemented, most of which might be perceived by its heavily criminal justice system clientele as coercive. One policy was to ask counselors to inform clients that
treatment is a condition of parole or probation and that leaving treatment can be reported.
Another provider made changes in its county-funded services for clients convicted of drunk
driving. As reimbursement for one state program waned and as this small provider generally struggled with state reimbursement rates, the executive director realized (with some
help from a state ofﬁcial) that revenues could be increased if DUI clients were ordered by
the provider to extend their number of visits, for which the clients were legally mandated to
pay. In another example, the executive director of an inpatient provider was replaced after
a ﬁnancial crisis (partly caused by changes in demand) hit. The new director increased
ﬁnancial stability by implementing a screening system that redirected the program away
from troubled clients who might quickly leave or might induce other clients to leave.
Ofﬁcials in three smaller and two larger providers report adopting other new management techniques that, while meant to increase the general efﬁciency of their organizations,
tended to treat clients as ﬁnancial resources. One reported technique was to use the economically efﬁcient mix of group and individual counseling. For example, a provider of
services to adolescents reported avoiding ﬁnancial problems, in part by considering funding
issues when determining the service mix. Group counseling, an agency ofﬁcial explained, is
reimbursed at a lower rate per individual than individual counseling, involves timeconsuming preparation, and can become expensive if many adolescents are ‘‘no shows.’’
Individual counseling can be overbooked to compensate for potential no shows. But more
clients can be served at one time in the groups.
Ofﬁcials in ﬁve providers report that they now regularly engage in waitlist management,
so that clients who can only be covered by unattractive funding sources can experience substantial service delays. In one vivid example, an ofﬁcial reports that the provider she staffed
decided to deal with the ﬁnancial crisis by fully rationing services by the state’s programs,
ﬁrst selecting off a long waitlist the types of clients who are more difﬁcult to ﬁnd in sufﬁcient
quantities to fully use available funding. The provider tries to immediately serve all private
insurance clients. The next priority is clients who are eligible for the Medicaid program, that
is, clients with welfare grants. Near the end of the month, the provider uses the state’s global
appropriation to easily ﬁll up on poor clients not otherwise covered. Further, women clients
who are eligible for funding from the DCFS program are served whenever openings arise.

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Issue 4. Long-Term Trends

Crises may last for a very long time, but in both Oregon and Illinois, the revenue picture
eventually began to improve. Moreover, the providers often regained ﬁnancial stability by
obtaining funds from outside the normal state substance abuse system. These improvements
make it possible to analyze whether crisis-related changes are permanent or only last
through the period in which the revenue picture declines. As the fourth proposition suggests, the evidence suggests that priorities and management routines that developed during
the crisis were maintained. It is argued below that this later stability partly reﬂects the key
institutional processes whereby priorities and practices adopted during the crisis became
taken for granted (accepted as the status quo). It also reﬂects the political process as described by punctuated equilibrium theory; the new policies favoring families over individuals gained political support.
Figure 2 demonstrates that only 5 of the 11 examined Oregon providers report being
worse off ﬁnancially in 2006 than in 2001. Two reportedly were about as well off, three
were better off, and a ﬁnal agency, a new for-proﬁt provider, was not in existence prior to
the crisis. (The director of the new provider perceived that ﬁscal crisis helped build up
demand for the provider’s low-cost services.) According to the interviewed executives
and as reported above, the providers in Oregon partly recovered ﬁnancially by obtaining
funding from ﬁelds whose budgets were not strongly affected by the crisis: corrections,
child welfare agencies, hospitals, and nonhospital general medical providers. They also
obtained funding from county courts, with which they served DUI cases. They kept to
the new priorities even when some state appropriations for OHP Standard clients were restored (in August of 2004), and even when, in Portland, I-Tax funds added revenues. One
reason for keeping to new priorities was that the state added an enrollment limit
(Oberlander 2006), but another was that the providers already closed down treatment
programs for the non-Medicaid population. They almost fully dedicated their limited treatment space to new populations.
At the level of health care policy, families took priority over single adults. Accordingly, when Oregon ﬁnancially recovered in 2006, the governor’s plans for expanding the
health system focused not on adding back services for OHP Standard clients but on meeting
the health needs of children (Oberlander 2006).
Table 2 also suggests that the interviewed Illinois providers never experienced large
revenue losses. In fact, eight providers reportedly grew slowly and one rapidly expanded.
But by 2006, the providers obtained revenues to serve different clients than they had in
2001, increasingly focusing on clients in the correction system, women with children,
or clients with mental health needs (as described above). Further, providers maintained
the new priorities when reimbursement rates mildly increased in 2006, since Medicaid
money, DCFS money, and the like were increased along with the global appropriation.
Of course, as documented above, providers also had become strategic thinkers who regularly mixed and matched speciﬁc revenue programs and reimbursement rates.
DISCUSSION
Study Implications

All in all, the current study suggests that crisis behavior biased service delivery in the studied states; coverage was narrowed and some services and population groups were

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Temporary Crises and Priority Changes

privileged at the expense of other very needy groups. For example, providers and state
actors tended to cover clients who were served by other state or federal systems (TANF
clients, criminal justice clients, child welfare clients, mental health clients). The providers
limited coverage of clients who had few external supports. The excluded clients tended to
be the most poor, the single clients, and those among the poor and single population who
lacked special (funded) problems. In Illinois, the expansion of recovery homes did help to
house single clients but without guaranteeing treatment (recovery homes do not necessarily
supply treatment).
Local conditions of arbitrary policy signiﬁcance also seemed to affect the patterns of
priority change. Most notably, large providers were more ﬁnancially successful than small
ones, apparently because size afforded providers the ability to meet such crisis-related
demands as to deliver inexpensive services or to shift from substance abuse to mental health
services. The long-term implications of that particular change are not fully known, but it
appears that states lost access to treatment slots in small, specialized programs that serve
difﬁcult to reach populations in unpopular geographic areas.
The crisis also appeared to induce changes that reﬂected special features of the states.
For example, methadone services were increased in Illinois but declined much more fully
than other services in Oregon (Deck, Witala, and Laws 2006). The difference in trends in
methadone treatment may reﬂect that Oregon heavily relied on Medicaid for funding, while
Illinois relied more heavily on the block grant; methadone services and treatment of heroin
problems in general are encouraged in the latter source. Administratively speaking, the
incentive systems on which states rely to regulate providers in the decentralized system
also was altered, with providers managing clients by revenue stream. Clients in one or both
states were put on waitlists or served by group work or individual counseling depending on
ﬁnancial rather than service matters.
Thinking broadly, the changes may reﬂect some of the incentives that are inherent in
the decentralized federal-state delivery system. Structurally, states have authority over
services but enjoy little political and social support. As a result, services are particularly
vulnerable to political disruption during a crisis. State actors who search for ways of regaining that support eventually turn to the ﬁnancially, socially, and politically powerful federal
government. In the period of interest, the federal government stressed certain services or
groups, like poor family heads. States also came to emphasize those services and groups.
Another underlying structural feature is that federal institutions are relatively strong; an
irony of the federally funded but state-administered system seems to be that it can undercut
the legitimacy of state programs. A further factor in this undercutting is the regular shifts in
political popularity of various problems or sets of clients. A ﬁnal factor is the existence of
mechanisms for service change, including provider-level budget ceilings and multiple
state-provided revenue streams.
More speculatively, the crisis-driven changes, while potentially long-lasting, may not
be fully permanent. Many of the priorities that changed after 2000 were developed in an
earlier era. In that era, homelessness was featured and single men were an important priority. Presumably, other population groups may have been featured before the homelessness ‘‘crisis.’’ It is conceivable that certain state policies periodically shift across crisis eras,
giving rise to regular declines in some activities and increases in others. As Provan and
Milward (2001) argue when discussing administration of provider-driven programs in
general, a resulting instability in priorities means that providers and state ofﬁcials are

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not able to fully garner the expertise needed to deal with one set of needs before they must
handle another. This pattern might be repeated in the late 2000s, that is, in another period
of crisis.
Study Limits

The analyses reported here, like most analyses, have technical limits. Some such limits, like
the fallibility of both interview and aggregate data and the limits of generalizability, seem
prevalent and perhaps endemic in case studies. However, causality seems to be strongly
supported by the ﬁndings. For example, state actors and representatives of providers reported
changes they usually said (exceptions are mentioned in the text) were speciﬁcally driven by
the crisis. Further, since similar alterations occurred in two very different states, change
appears to be driven by the state crises rather than by the special trends or characteristics
of either state. In Oregon, data directly suggest that the crisis reversed previous trends (such
as the trend toward increasing coverage of substance abuse services for poor single individuals). Results also conform to available theory. For example, many of the trends are compatible with regulative isomorphism, whereby a state’s hand in a crisis is forced by federal
regulations and where institutional pressures work themselves out at the provider level.
The little that is known about responses to other crises helps to suggest that the current
results are generalizable; a rereading of history suggests a general tendency for states and
providers to follow federal trends when adjusting to crises. For example, such large-scale
crises as the Great Depression obviously spurred the central government to take the lead in
forming service priorities. Further, although researchers do not acknowledge it, similar
subtle changes to those documented in the current work may have occurred shortly after
the welfare state crisis. Kimmich (1986) shows that state reactions to the Reagan budget
cuts were as complicated as might beﬁt a reform that reorganized services. Nevertheless,
she reports that states eventually found ways to maintain or increase funding for child welfare services and child care. She ties the state changes to new federal legislation concerning
child welfare and work-related child care, and she thus indirectly suggests that states were
able to restore funding by emphasizing federal priorities. Her work also conﬁrms that the
state strategies were linked both to federal legislation that increased monetary incentives
and to the social and political support states could garner for following the new federal
priorities. States also increased reimbursement for services from Medicaid. Berne and
Steifel (1993) also show that a crisis spurred long-lasting priority changes.
CONCLUSION

One practical suggestion emerging from the ﬁndings is that ofﬁcials might adopt a routine
after-crisis assessment of their priority and administrative changes. In this assessment, ofﬁcials might analyze whether the changes that occurred during a crisis are valuable or
whether those changes actually distort preferred priorities. For example, a reassessment
by ofﬁcials in Oregon may suggest that it is not appropriate to continue the shifts in
the early 2000s from substance abuse to mental health services or that providers’ new ﬁscal
strategies are harmful to clients and should be modiﬁed. Without a reassessment, crisisinduced changes might mistakenly remain in effect.
A broader reading of the ﬁndings might at ﬁrst glance seem to suggest that crises-induced
changes have public management beneﬁts; they spur reform in systems that otherwise change

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Temporary Crises and Priority Changes

slowly. For example, it may be argued that the reactions to the crisis in substance abuse services helped to refocus Illinois programs on important priorities like drug abuse services, recovery homes, and the problems of women. The crisis also arguably spurred a tightening up in
the ﬁnancing of providers. However, when considered further, the documented patterns of
change seem to be more problematic than beneﬁcial. For example, ﬁndings suggest that Illinois and Oregon reversed valued priorities and reduced unique service offerings.
Indeed, study ﬁndings help to generally question the beneﬁts of the decentralized administrative approach. Due to decentralization, local and state public authorities oversee
fragmented, complex, and evolving service systems. In such systems, ﬁscal crises tend to
weaken the bargaining position of local providers and reduce the commitment of state legislatures to service programs. State authority also is severely tested during crises, in part
because of general limits to that authority; programs funded by the federal government
are not demanded by and thus not heavily politically supported in states. Federal legislation
generally allows state bureaucracies to be underfunded and understaffed. Accordingly,
when crises occur, the state administrators have limited capacity to maintain independent
service priorities. The administrators instead tend to mimic federal priorities, thereby reversing the very beneﬁts of local control that decentralization ostensibly provides. Moreover, the changes made during a crisis can remain in effect for a long period.
In short, under decentralization, service delivery systems seem to be restructured in unintended and undesirable ways by periodic, crisis-related, transformations. Ironically, then,
although Levine and colleagues argued that centralized local authorities were better positioned to deal with cuts of the 1970s than decentralized and fragmented local authorities
(Levine, Rubin, and Wolohojian 1981), the current evidence suggests that local authorities
of all kinds are now decentralized and have limited capacities to deal with crises. Indeed, to the
extent to which the limits to state and local administrative capacities are inherent in the current
way of organizing, it may be worthwhile to reconsider the extent to which the basic decentralized structure of contemporary federal service programs actually helps to empower states.

FUNDING

Support for the data collection was provided by the Center for Health Administration
Studies, The University of Chicago.
APPENDIX 1
State-Level Interview
Overview

We seem to be in a time period in which legislative appropriations for substance abuse
treatment are more or less ﬂat (in Oregon: are declining). Our project is analyzing how
substance abuse treatment agencies respond to this, especially given that they previously
experienced an era of expansion. For example, are agencies innovating services, cutting
back, or something else? How are they selecting clients?
This project largely involves interviewing agency heads in Illinois and also in Oregon.
We are talking to you because we also are looking for the state’s perspective on how agencies are doing and, also, your perspective on how state policies are changing and how that
affects agencies.

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Funding Issues

How tight do you see funding for substance abuse providers? Does the state see the situation
as a crisis or just a problem? What type of speciﬁc issues do you see emerging? Are some
sources of funds more problematic than others? That is, is funding increasing from some
sources, but not from others?
Are there increases in special areas? If this involves new money, what is the source? Is
it used as an add-on or to replace other money?
Is the new emphasis on MISA12 clients affecting the budget in any way?
Are other state or federal policies changing in important ways with respect to sources
of funds, like the block grant/Medicaid/state general revenue funds?
Do you see any changes in state emphases stemming from all such changes? Any new
strategies for attracting revenue?
Overall Service Emphases

Financial priorities relate to service priorities. We are also trying to ask about the mix of
services in agencies and how agencies change that mix. So far, agencies we visited seem to
be acting rather differently. But we would like to understand how policies matter, here.
Does the state have any plan or priorities on the characteristics of agencies, services:
Mix between detox, residential, inpatient, recovery homes, levels of outpatient
Geographic mix
Priority populations/ethnic coverage
Prevention services versus treatment services
Adults versus children

To what extent do such priorities, above, stem from the state agency, state legislature,
federal regulations?
Are any of these priorities changing? How are priorities translated to agencies? That is,
is money shifting from one or another type of service in general? Are agencies being excluded or asked to change services?
We got the sense that different agencies told us different things about the rules they are
under in serving priority populations, especially various outpatient agencies. Are all agencies expected to service given priority populations? Which ones? Is this changing over
time?
Can agencies shift funding among priority populations? Is this changing over time?
If agencies have different mandated priority groups, how is that established?
We understand that this agency also has some programmatic initiatives. What are
those and how are those being funded?
Any particular way for coming up with such initiatives? How many/which ones are
agency generated initiatives?
More generally, how heavily does the state consider the service technologies agencies
use—how evidence-based practice is, for example.

12
The abbreviation MISA was in the document used by the interviewers. MISA stands for Mentally Ill, Substance
Abusing.

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Funding Priorities

We understand substance abuse funding is partly from the block grant, partly from the state,
and partly from Medicaid or the Department of Family Services. Your agency also is always
looking for special SAMHSA13 funding. Agencies seem to have different mixes. How are
decisions made about that mix? Do agencies ever try to change the mix of funds? Is there
a formal application process for this?
We have heard different things about yearly adjustments, that is, end of the year
money. How does that money get generated? What are the processes for spending
it—RFP14, special grants to given agencies, etc.?
We know that there are different rates for different types of services. Are these established by the state or the legislature? Are the rates revisited at regular intervals?
Speciﬁc Social Organization

How often does the state close or start funding agencies? How are those decisions made?
Any particular patterns or changes in recent years?
How would you generally assess the functioning/viability of agencies? Are there special concerns or issues in working with large or small agencies? Are there differences in the
procedures or policies used with each?
Any speciﬁc goals in changing the way agencies behave or which agencies are
funded?
Does your agency worry about the funding source in setting rates or any other sorts of
rules? That is, do rules vary by source, and does this have any implications for how agencies
are changing?
Your agency of course has service dollar caps. What happens to agencies that do not
meet those caps? What happens to their appropriation? We have the impression some agencies are put on some sort of budget timeline if they are falling behind?
Some, but not all, agencies say they are under speciﬁc guidelines for co-payments/
matches. What are the guidelines? Why does your agency have guidelines? Do agencies
match Medicaid funding?
Agencies seem to make decisions about such matters as whether to use regular versus
intensive outpatient treatment. They say they use ASAAM15 [sic] criteria. Do you know
how those criteria are applied and how the state monitors the application of criteria?
APPENDIX 2
Provider Interview Schedule
Agency/Respondent Background—Opener

 Tell me a bit about your background in substance abuse treatment and your role here at the
agency? (education/training/experience, job title, general duties)

The abbreviation SAMHSA was in the document used by the interviewers. SAMHSA stands for the Substance
Abuse and Mental Health Services Administration.
14
The abbreviation RFP was in the document used by the interviewers. RFP stands for Request for Proposal.
15
The incorrect name, ASAAM, was in the document used by the interviewers. ASAAM should be ASAM, which
stands for the American Society of Addiction Medicine.
13

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Journal of Public Administration Research and Theory

s

What is the history of the agency?

s

Commitment to SA16 services

s

Afﬁliations with larger entity

s

Nonproﬁt or for-proﬁt

s

Substance abuse services delivered

s

Historical changes in service delivery

s

Staff size and characteristics

Agency Service Background **Ask for any informational materials about the agency
services**

 Service methods
s

s

s

Tell about services provided at your agency (both within the area of substance abuse
treatment and other services).
(If provide more than SA) What proportion of agency resources (staff, budgetary,
clients) are devoted to substance abuse treatment?
Do you have more than one substance abuse treatment program? We have the
following information, is this correct? If not, what are the different programs?

Agency Service Technology (service under discussion)

 Describe the intake process
s

What is the process like?

s

Who makes admissions decisions?

s

What criteria are used in these decisions?

s

(If there are multiple SA programs/levels of services) How are decisions made as to
which services clients receive which type of service

 What is the general service method (for primary OR each service technology)?
s

s

s

16

Do you rely on a 12-step approach, another approach or a combination?
To what extent do you use speciﬁc treatment technologies (e.g. cognitive behavioral
therapy, motivational interviewing, incentive or voucher systems, acupuncture,
psychodynamic therapy, family therapy, other techniques, medication or drug
therapies)?
Who receives each type of intervention (therapeutic technique and drug) and how
often?

The abbreviation SA was in the document used by the interviewers. SA stands for Substance Abuse.

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s

s

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Temporary Crises and Priority Changes

Do you offer social services? If so which ones? Where are they offered? How
many substance abuse treatment clients receive each (and which clients receive
them)?
Are clients referred to social services outside your agency? If so, for which services?
Which clients? How many receive these services? For how long do they receive
these services?
Are clients referred to any other types of services (offered within your agency or
outside)? If so, which ones and how often?
Are there follow-up/aftercare services provided after clients complete the program?

 Do you have different levels of treatment? What are the different levels? What are the criteria
for getting into each level? Do clients change levels? Why and how often?
 Could you describe clients’ regular schedules (daily/weekly)? **ASK FOR COPY OF
SCHEDULES**
s

How often are clients seen individually and how often in groups? Does this vary by
client type?

s

Number of hours, times for each service

s

Services/treatments received both within agency and outside

 Length of stay
s

What is the intended length of stay in the program?

s

What is the immediate dropout rate?

s

What is the actual average length of stay? (Does this include immediate dropouts?)

s

Do dropouts ever return? If so, how many?

 Outcomes **ASK FOR ANY MATERIALS USED TO REPORT OUTCOMES**
s

s

How is performance evaluated? (e.g., program retention and completion, length of
sobriety)
What is known about outcomes?

Clients/Referral Source

 About how many clients are in (primary/each) substance abuse service programs at your
agency? By day, by year?
s

Does your agency’s caseload tend to vary (by day, by week, by time of year)?

s

How many formal ‘‘slots/beds’’ do you have in your program(s)?

 Could you describe the breakdown in terms of clients’ primary drug problem?
s

Alcohol

s

Cocaine/crack

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Journal of Public Administration Research and Theory

s

Heroine/karachi

s

Marijuana/hashish

s

Hallucinogens

s

Methamphetamines

s

Poly drug

s

Other

 What is the demographic breakdown?
s

Children/adults and ages amongst adults

s

Male/female

s

Race

s

Economic/employment status

s

Private pay/subsidized

 How do clients reach the agency
s

s

s

Self-referred or referred by another agency
Do you have any special arrangements (formal or informal) with agencies or organizations providing referrals? If so which ones and what are the arrangements?
Can you reject clients referred by these agencies? Does this vary by client type? By
referral source?

 Is it difﬁcult to get new clients?
s

s

Does this vary by client type?
Are those clients that are attached to ﬁnancial resources more or less difﬁcult to bring
in to the agency?

Staff

 How many staff are within the agency? **ASK FOR ORGANIZATIONAL FLOW
CHART/MATERIALS**
s

s

(If mixed service agency) How many are entirely devoted to substance abuse
treatment?
How many are devoted to substance abuse treatment at least part-time?

 Could you describe your substance abuse treatment staff’s background?
s

Education

s

Training

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Temporary Crises and Priority Changes

s

Experience

s

Preferred treatment approach

s

History with substance abuse (PERSONAL OR PROFESSIONAL)

s

Professional afﬁliations, certiﬁcations, licenses. Are these required?

 Do staff regularly attend professional meetings?
s

If so, which ones and how often?

 What types of in-service training do you offer?
s

Are these required?

 Do all staff use the same methods/techniques/technologies in treating clients?
s

Is treatment method/technique/technology determined by agency policy?

s

How much discretion do staff have in choosing treatment method?

Relationship with the General Environment

 Are you accredited by any associations?
s

Which ones?

s

Is this important to your agency? How?

 Are you licensed by any agencies/associations?
s

Which ones?

s

To do what?

 Do you belong to any associations or organizations with other substance abuse agencies
locally or nationally?
s

Which ones?

s

What do these associations/organizations do?

s

Is this important to your agency? How?

 In addition to the above, do you have regular contacts with other substance abuse agency
professionals?
s

Are there particular issues/changes in other agencies about which you try to keep
informed?

s

Do agencies work together toward a common agenda? How?

s

To what extent do you compete with other agencies for resources? (funding, clients)

 How do you try to keep up on issues in the funding and treatment environment?
s

Do you maintain contacts with state and local ofﬁcials?

s

Keep up with professional literature?

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Journal of Public Administration Research and Theory

s

Depend on staff to inform you of professional developments?

s

Maintain ties to important outsiders?

s

Rely on your Board of Directors?

s

Other ways?

 What is your general perception of resources available to substance abuse treatment organizations in Illinois/Oregon?
s

Are they diminishing? Growing?

s

Do you think that resources are tighter overall?

s

s

s

Do you think some organizations (or types) are better positioned than others to thrive
in this environment?
Do you think there is increased competition between agencies for ﬁnancial resources? Explain. Can you give examples?
Do you think there is increased competition between agencies for clients? Explain.
Can you give examples?

Agency Fiscal Background **ASK FOR ANNUAL REPORT, ANY FINANCIAL DOCUMENTS
WILLING TO SHARE**

 What is your total budget? (for SA treatment)
s

What are your major funding sources?

s

What percent of total dollars come from each?

s

s

What are the conditions for obtaining funds from each source? Is money provided for
a particular program? For a particular type of client? Is payment provided per service
hour? Per outcome?
Are you under contract with each funding source? Could you describe these contracts (length of contract, treatment speciﬁc, client speciﬁc).

 Do you receive managed care contracts?
s

If so, please describe these?

s

How many do you have?

s

Are these formal contracts?

s

Do you accept all possible managed care arrangements?

s

If not, how do you select those you accept?

 Could you tell us a bit about your relationship with various funders (focus ﬁrst on
state)?
s

Do you regularly interact with funding agency staff? If so, in what capacity?

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Temporary Crises and Priority Changes

How would you characterize your agency’s relationship with each funder? Cooperative? Contentious?

s

In what ways do you rely on each funding agency?

s

In what ways does each funding agency rely on your agency?

s

How closely are you monitored by each funder?

s

Do you ever receive special offers to receive additional funding or provide special or
additional services during each ﬁscal year? If so, explain. How often does this occur?
Could you give a recent example?

 In general, what is your basic strategy for funding the agency?
s

Ideally, do you prefer one or many funding sources? Why?

s

Do you try to keep the organization stable?

s

Look for added revenues?

s

Tried to implement latest practice innovations?

s

Look for niches where there are few competitors?

 Do you ﬁnd that funding sources are stable?
s

If not, do you regularly act to maintain or change funding sources?

 What sort of pressures or demands related to client services come from the funding agencies?
s

s

s

s

Do you ﬁnd that improving the quality of client services has any implications for
obtaining funds or satisfying the agencies?
How do you make decisions regarding your service mix? How about your client
mix? Do reimbursement rates factor into these decisions? How?
Are there other strategies you use to make sure that your agency is viewed favorably
by these funders? If so, how is this done?
Does your agency regularly search for new funding? New sources of clients? New
types of services? New service technologies?

General Strategies
Recent Fiscal Conditions

We are particularly interested in how agencies respond to changes in funding and how these
changes affect service delivery. First, I am going to ask you about general funding strategies
changes, and then I will ask you about speciﬁc changes in the categories (services, service
technologies, clients/referrals, stafﬁng and external environment) we just discussed.
Funding Strategy Changes

 Have there been any major changes in funding sources or the amounts over the last three
years?
s

What were they? What types of pressures or strains did they place on the agency?

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Journal of Public Administration Research and Theory

s

In particular, have you been affected by changes in government funding or policies?

s

Changes in managed care regulations?

s

Changes in licensing or accredation?

s

Changes in client demand? (demand levels or in types of clients/needs of clients)

s

Changes in types of clients?

s

Changes in referral source priorities?

s

s

Changes in the level of certainty of continuing funding in general, and of continuing
funding at a given level
Changes in demands placed on the agency by funding sources

 Have there been changes in sources of funds?
s

Have you searched elsewhere for revenues?

s

Clients?

s

How successful have you been?

 Have you tried to increase private insurance or insurance based clients?
s

In what ways

s

How successful have you been?

 Have you tried to ‘‘repackage’’ services for new funding sources?
 Have you attempted to diversify within the area of substance abuse treatment? Outside of it?
s

Describe these attempts?

s

Have you been successful?

 Has this helped your agency’s ability to continue with its substance abuse treatment services?
Describe?
General Changes in Service Delivery and Agency Structure

 Have there been any changes within the last 3 years in the following:
s

Service categories?

s

Service technologies employed?

s

Clients and referral sources?

s

Stafﬁng?

s

Relationship with external environment

 Do you think any of these changes are a result of funding changes? A result of strategic efforts
to improve services to your clients? A mix of both?

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 Do you think that your agency’s ability to balance clients’ needs and the demands of funding
sources has changed? How? Can you give an example?
Follow-Up to General Changes

 How have service categories changed?
s

s

s

Such as inpatient, outpatient . . .
Non–substance abuse services offered at your agency? (types of services offered,
level of services)
Do you think changes in the service categories have affected your agency’s ability to
help your clients overcome substance abuse issues?
n Overall quality of services
n Holistic nature of services
n Has it affected dropout rates
n Has it affected completion rates
n Overall program success

 How have service technologies changed?
s

s

s

Have they expanded/contracted
Have you changed procedures, like altering the number of treatment options for each
client?
(If there are new programs) Do you ﬁnd any challenges maintaining your previous
services as you add or change programs?

s

Have overall costs/client or costs/outcome changed?

s

Planned and actual length of stay for clients? Waiting lists?

s

Do you think changes in the length of care have affected your agency’s ability to help
your clients overcome substance abuse issues?
n Overall quality of services
n Holistic nature of services
n Has it affected dropout rates
n Has it affected completion rates
n Overall program success

 How have clients and referrals changed?
s

Such as the types of clients you target for speciﬁc program

s

the client mix (DUI, private insurance, etc.)

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s

Number of clients served

s

Demographics of clients

s

Referral sources and how clients selected (creaming)
n What new criteria/considerations must you now consider in selecting clients?
n If services are tiered, how are decisions made as to who gets which service levels
(creaming)

s

How have changes in your client mix affected your agency in terms of . . .?
n Overall quality of services
n Holistic nature of services
n Dropout rates
n Completion rates
n Overall program success

 How has stafﬁng changed?
s

Staff size, ratio of staff to clients.

s

If there staff reductions, on what basis were they made?

s

Changes in use of volunteers

s

Cutting back on beneﬁts or salaries

s

Used other nontraditional ways of dealing with ﬁscal strains related to stafﬁng

s

Number of staff devoted to non–substance abuse treatment services

s

Staff time devoted to non-substance abuse treatment services

s

Does this reﬂect a desire to get non-SA clients or is this an attempt to provide (and
create revenue from) additional services to existing client groups.

 Relationship with environment (external and strategic changes)?
s

Have there been changes in your service mix, that is in . . .
n The ratio of substance abuse to other services,
n The types of substance abuse services?

s

Have you increased your connections with other agencies in other ways?
n For example, have you increased activities on joint activities?
n Tried to start joint programs or referral networks?
n Done something else?

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Temporary Crises and Priority Changes

Have you become more competitive with other agencies?
n If so, which ones?
n How have you become more competitive with these agencies? To what do you
attribute this increased competition?

s

Have you changed or increased your overall strategic planning?
n Describe. What types of strategic planning are you engaged in and how has this
changed? Is this a result of ﬁscal changes? Explain?

s

s

Have you changed or increased your ﬁnancial planning activities within the agency?
Explain?
Have your agency changed in terms of its level of professionalization, that is . . .
n Has it become more or less important that your staff are connected to other
substance abuse treatment professionals?
n Has the importance of staff education, training and experience become more of
less important?
n Has it become more or less important that staff stay abreast of latest treatment
practices? Read journal articles on substance abuse treatment?
n Attend lectures on substance abuse treatment?

s

s

To what extent do you think it is important for your agency to respond to and reﬂect
generally accepted practices amongst substance abuse professionals?
How has this changed?

 Has the role of your agency’s Board of Director’s changed?
s

How?

s

Is this a result of funding changes?

 Has your agency considered leaving substance abuse services altogether?
 Has the agency considered changing its nonproﬁt/for-proﬁt status?

REFERENCES
Alexander, Jennifer. 2000. ‘‘Adaptive strategies of nonproﬁt human service organizations in an era of
devolution and new public management.’’ Nonproﬁt Management and Leadership. 10:287–303.
Alexander, Jennifer, Renee Nank, and Camilla Stivers. 1999. ‘‘Implications of welfare reform: Do
nonproﬁt survival strategies threaten civil society?.’’ Nonproﬁt and Voluntary Sector Quarterly.
28:452–75.
Agranoff, Robert, and Michael McGuire. 1998. ‘‘Multi-network management: Collaboration and the
hollow state in local economic policy.’’ Journal of Public Administration Research and Theory
8:67–91.
Ang, Soon, and Larry L. Cummings. 1997. ‘‘Strategic responses to institutional inﬂuences on information
outsourcing.’’ Organizational Science 8:235–56.

571

572

Journal of Public Administration Research and Theory

Bartle, John R. 1996. ‘‘Coping with cutbacks: City response to aid cuts in New York state.’’ State and
Local Government Review 28:38–48.
Baumartner, Frank, and Bryan Jones. 1993. Agendas and instability in American politics. Chicago, IL:
Univ. of Chicago Press.
Behn, Robert D. 1980. ‘‘Leadership for cut-back management: The use of corporate strategy.’’ Public
Administration Review 40:613–20.
Behn, Robert D., and Elizabeth Keating. 2004. ‘‘Facing the ﬁscal crises in state government: National
problem, national responsibilities.’’ State Tax Notes 33:833–47.
Berne, Roberta, and Leanna Stiefel. 1993. ‘‘Cutback budgeting: The long-term consequences.’’ Journal of
Policy Analysis and Management 12:664–84.
Bischoff, Ursula M., and Michael S. Reisch. 2000. ‘‘Welfare reform and community-based organizations:
Implications for policy, practice and education.’’ Journal of Community Practice 8:69–91.
Bowling, Cynthia J., and Brendan F. Burke. 2006. ‘‘Levine’s legacy: Comparing state administrative
strategies to treat ﬁscal stress, 1984–2004.’’ Paper prepared for the 7th State Politics and Policy
Conference. Lubbock, TX, May 19–20.
Boyd, Donald. 2003. The current state ﬁscal crisis and its aftermath. Washington, DC: Kaiser Commission
on Medicaid and the Uninsured. http://www.kff.org/medicaid/upload/The-Current-State-FiscalCrisis-and-Its-Aftermath-PDF.pdf (accessed April 2008).
Brodkin, Evelyn. 2005. ‘‘Toward a contractual welfare state? The case of work activation in the U.S.’’
Contractualism in employment services: A new form of welfare state governance. London: Klumer
Law International.
Cahill, Anthony G., Joseph A. James, Jean E. Lavigne, and Ann Stacey. 1994. ‘‘State government responses to municipal ﬁscal distress: A brave new world for state-local intergovernmental relations.’’
Public Productivity and Management Review 17:253–64.
Clemens, Elisabeth S., and James M. Cook. 1999. ‘‘Politics and institutionalism: Explaining durability and
change.’’ Annual Review of Sociology 25:441–66.
Conlan, Timothy J. 1984. ‘‘The politics of federal block grants: From Nixon to Reagan.’’ Political Science
Quarterly 99:247–70.
Deck, Dennis D., Wyndy L. Witala, and Katherine E. Laws. 2006. ‘‘Medicaid coverage and access to
publicly funded opiate treatment.’’ The Journal of Behavioral Health and Research 33:324–34.
DiMaggio, Paul, and Walter Powell. 1983. ‘‘The iron cage revisited: Institutional isomorphism and
collective rationality in organizational ﬁelds.’’ American Sociological Review 48:147–60.
Finegold, Kenneth, Stephanie Schardin, and Rebecca Steinbach. 2003. How are States responding to ﬁscal
stress? Urban Institute, Series A, No. A-58. http://www.urban.org/url.cfm?ID5310658 (accessed
April 2007).
Fligstein, Neil. 1991. ‘‘The structural transformation of American industry: An institutional account of the
causes of diversiﬁcation in the largest ﬁrms, 1919–1979.’’ In The new institutionalism in organizational analysis. edited by W. Powell and P. DiMaggio.
Flora, Peter and Arnold J. Heidenheimer, eds. 1982. The development of welfare states in Europe and
America. New Brunswick, CT: Transaction Books.
Frederickson, Patricia, and Rosanne London. 2000. ‘‘Disconnect in the Hollow State: The pivotal role of
organizational capacity in community-based development organizations.’’ Public Administration
Review 60:230–39.
Gabriel, Roy M., and Dennis D. Deck. 2004. Substance abuse services under the Oregon health plan: Still
changing after all these years. Presentation to the Oregon Health Research & Evaluation Collaborative. Portland, Oregon, December. http://www.oregon.gov/OHPPR/OHREC/Docs/Presentations/
SASStillChng12_04_ppt.pdf (accessed April 2007).
Geiger, Theodore. 1978. Welfare and efﬁciency. Washington, DC: National Planning Association.
Gold, Steven. 1992. ‘‘The federal role in state ﬁscal stress.’’ Publius 22:33–47.
Governor’s Council on Alcohol and Drug Abuse Programs. 2006. The Domino effect: A business plan for
rebuilding substance abuse, treatment and recovery, 2007–2009 http://www.oregon.gov/DHS/
addiction/gov_council/main.shtml (accessed April 2007).

Sosin et al.

Temporary Crises and Priority Changes

Greenwood, Royston, and C. R. Hinings 1996. ‘‘Understanding radical organizational change: Bringing
together the old and new institutionalism.’’ The Academy of Management Review 21:1022–54.
Greenwood, Royston, Roy Suddaby, and C. R. Hinings. 2002. ‘‘Theorizing change: The role of professional associations in the transformation of institutional ﬁelds.’’ Academy of Management Journal
45:45–57.
Gronbjerg, Kirsten, James C. Musselwhite, and Lester Salamon. 1984. Government spending and the
nonproﬁt sector Washington, DC: Urban Institite.
Gutowski, Michael, and Jeffrey J. Koshel. 1982. ‘‘Social services.’’ In The Reagan experiment, eds. John
L. Palmer and Isabel V. Sawhill. Washington, DC: Urban Institute 307–28.
Hevesi, Alan. 2005. 2005 Annual report on local government. Ofﬁce of the New York State Comptroller,
Division of Local Government Services and Economic Development. Albany, NY. http://
www.osc.state.ny.us/localgov/annualreport905.pdf (accessed April 2008).
Hirsch, Fred. 1976. Social limits to growth. Cambridge, MA: Harvard Univ. Press.
Hoffman, Andrew, and Marc Ventresca. 1999. ‘‘The institutional framing of policy debates.’’ American
Behavioral Scientist 42:1368–92.
Holohan, John, Joshua M. Weiner, Randall R. Boybjerg, Barbara A. Ormond, and Stephen Zuckerman.
2003. The state ﬁscal crisis and Medicaid: Will health programs be major budget targets?
Washington, DC: Kaiser Commission on Medicaid and the Uninsured. http://www.kff.org/medicaid/
loader.cfm?url=/commonspot/security/getﬁle.cfm&PageID=14312 (accessed April 2008).
Hood, Christopher. 1991. ‘‘A public management for all seasons.’’ Public Administration 69 (1): 3–19.
Ingram, Paul, and Tal Simons. 1995. ‘‘Institutional and resource dependence determinants of responsiveness to work-family issues.’’ The Academy of Management Journal 38:1466–82.
Johansson, Staffan. 2003. ‘‘Independent movement or government subcontractor?—Strategic responses of
voluntary organizations to institutional processes.’’ Financial Accountability and Management
19:209–24.
Johnson, Nicholas. 2002. The state tax xuts of the 1990s: The current revenue crisis, and implications for
state services. Washington, DC: Center for Budget and Policy Priorities. http://www.cbpp.org
(accessed April 2007).
Kettl, Donald. 1997. ‘‘The global revolution in public management: Driving themes, missing links.’’
Journal of Policy Analysis and Management 16:446–62.
Kimmich, Madeleine H. 1986. American children who cares? Growing needs and declining assistance in
the Reagan era. Washington, DC: Urban Institute Press.
Lane County Health and Human Services. 2006. Lane County Mental Health and Addictions Implementation Plan, 2007–2009. Eugene, OR: Lane County Health and Human Services.
Lav, Iris J. 2007. Federal grants to states and localities cut deeply in ﬁscal year 2008 budget. Washington,
DC: Center for Budget and Policy Priorities. http://www.cbpp.org (accessed April 2007).
Leblebici, Huseyin, Gerald R. Salancik, Anne Copay, and Tom King. 1991. ‘‘Institutional change and the
transformation of interorganizational ﬁelds: An organizational history of the U.S. radio broadcasting
industry.’’ Administrative Science Quarterly 36:333–63.
Levine, Charles H. 1978. ‘‘Organizational decline and cutback management.’’ Public Administration
Review 38:316–25.
———. 1979. ‘‘More on cutback management: Hard questions for hard times.’’ Public Administration
Review 39:179–83.
Levine, Charles H., Irene S. Rubin, and George G. Wolohojian. 1981. The politics of retrenchment: How
local governments manage ﬁnancial stress. Beverly Hills, CA: Sage.
Lipsky, Michael. 1981. Street level bureaucracy. New York: Russell Sage.
Lynn, Laurence E. 2002. ‘‘Social services and the state: The public appropriation of private charity.’’
Social Service Review 76:58–82.
Mann, Cinty, and Samantha Artiga. 2004. The impact of recent changes in health care coverage for lowincome people: A ﬁrst look at the research following changes in Oregon’s Medicaid program
Washington, DC: Kaiser Commission on Medicaid and the Uninsured. http://www.kff.org/medicaid/
upload/The-Impact-of-Recent-Changes-in-Health-Care-Coverage-for-Low-Income-People-A-

573

574

Journal of Public Administration Research and Theory

First-Look-at-the-Research-Following-Changes-in-Oregon-s-Medicaid-Program.pdf (accessed
April 2008).
Meyer, John, and Brian Rowan. 1977. ‘‘Institutionalized organizations: Formal structures as myth and
ceremony.’’ The American Journal of Sociology 83:340–63.
Milward, H Brinton. 1993. ‘‘Nonproﬁt contracting and the hollow state.’’ Public Administration Review
54:73–7.
Milward, H. Brinton and Keith G. Provan. 2000. ‘‘Governing the hollow state.’’ Journal of Public
Administration Research and Theory 10:359–79.
Mirabella, Roseanne M. 2001. ‘‘A symposium introduction: Filling the hollow state: Capacity building
within the nonproﬁt sector.’’ Public Performance and Management Review 25:8–13.
National Association of State Budget Ofﬁcers. 2002. The ﬁscal survey of the states. http://www.nasbo.org/
Publications/ﬁscalsurvey/nov2002ﬁscalsurvey-revisedFL.pdf (accessed January 2007).
———. 2006. The ﬁscal survey of the states. http://www.nasbo.org/Publications/PDFs/FiscalSurvey
June06.pdf (accessed April 2007).
Oberlander, Jon. 2006. ‘‘Health reform interrupted: The unraveling of the Oregon health plan.’’ Human
Affairs 19:w96–105.
Ocasio, William. 1999. ‘‘Institutionalized action and corporate governance: The reliance on rules and CEO
succession.’’ Administrative Science Quarterly 44:384–416.
O’Connor, James. 1973. Fiscal crisis of the state. New York: St. Martin’s Press.
Offe, Claus. 1984. Contradictions of the welfare state. Cambridge, MA: MIT Press.
Ofﬁce of Mental Health and Addiction Services, Department of Human Services. 2006. Brieﬁng paper
prepared for representative Phil Barnhart. Eugene, OR: OMHAS.
Oliver, Christine. 1991. ‘‘Strategic responses to institutional processes.’’ The Academy of Management
Review 16:145–79.
Oregon Health Services Commission. 2004. SFS 2006–07 Benchmark Rate Study, Oregon health plan.
Eugene, OR: Oregon Health Services Commission.
———. 2007. CY 2008-09 Benchmark Rate Study, Oregon health plan, summary report. Eugene, OR:
Oregon Health Services Commission.
Pierson, Paul. 2004. Politics in time: History, institutions, and social analysis. Princeton, NJ: Princeton
Univ. Press.
Pollack, Harold, Sheldon Danziger, Kristin S. Seefeldt, and Ruckmalie Jayakody. 2002. Substance use
among welfare recipients: Trends and policy implications. Social Service Review 76:256–74.
Poterba, James M. 1994. ‘‘State responses to ﬁscal crises: The effects of budgetary institutions and
politics.’’ The Journal of Political Economy 102:799–821.
Provan, Keith G, and Brinton Milward. 1991. ‘‘Institutional-level norms and organizational involvement
in a service-implementation network.’’ Journal of Public Administration Research and Theory
1:391–417.
———. 2001. ‘‘Do networks really work? A framework for evaluating public sector organizational
networks.’’ Public Administration Review 61:414–23.
Rao, Hayagreeva. 1998. ‘‘Caveat emptor: The construction of nonproﬁt consumer watchdog organizations.’’ The American Journal of Sociology 103:912–61.
Reisch, Michael, and David Sommerﬁeld. 2003. ‘‘Interorganizational relationships among nonproﬁts in
the aftermath of welfare reform.’’ Social Work 48:307–14.
Reschovsky, Andrew. 2003. ‘‘The implications of state ﬁscal stress for local governments.’’ Paper
prepared for Urban Institute conference, State Fiscal Crises: Causes, Consequences, and Solutions,
Washington, DC, April. http://www.taxpolicycenter.org/sfc2003/pdf/Reschovsky-ﬁscal-crisispaper-FINAL.pdf (accessed April 2008).
Romzek, B. S., and J. M. Johnston. 2005. ‘‘State social service contracting: Exploring the determinants of
effective contract accountability.’’ Public Administration Review 65:462–74.
Scott, Richard W. 2001. Institutions and organizations, 2nd ed. Thousands Oaks, CA: Sage Publications.
Smith, Steven Rathgeb. 2002. ‘‘Social services.’’ In The state of nonproﬁt America. In Lester M. Salamon,
ed. Washington, DC: Brookings, pp. 149–86.

Sosin et al.

Temporary Crises and Priority Changes

———. 2007. ‘‘Medicaid funding of social services: Implications for social and health policy.’’ Paper
presented at the Annual Meeting of the American Political Science Association, Chicago, IL, August.
Smith, Steven Rathgeb, and Michael Lipsky 1993. Nonproﬁts for hire: The welfare state in the age of
contracting. Cambridge, MA: Harvard Univ. Press.
Sosin, Michael R. 1990. ‘‘Decentralizing the social service system: A reassessment.’’ Social Service
Review 64:617–36.
Sosin, Michael R., Paul Colson, and Susan Grossman. 1988. Homelessness in Chicago: Poverty and
pathology, social institutions and social change. Chicago: The Chicago Community Trust.
Suchman, Mark. 1995. ‘‘Managing legitimacy: Strategic and institutional approaches.’’ The Academy of
Management Review 20:571–610.
Swidler, Ann. 1986. ‘‘Culture in action.’’ American Sociological Review 51:273–86.
Terry, Larry D. 2005. ‘‘The thinning of administrative institutions in the hollow state.’’ Administration and
Society 37:426–44.
Tolbert, Pamela S. 1985. ‘‘Resource dependence and institutional environments: Sources of administrative
structure in institutions of higher education.’’ Administrative Science Quarterly 30:1–13.
Van Slyke, David M. 2006. ‘‘Agents or stewards: Using theory to understand the government-nonproﬁt
social service contracting relationship.’’ Journal of Public Administration Research and Theory
17:157–87.
Western Rural Development Center. 2003. The ﬁscal crisis in state government: A focus on 13 western
states. http://extension.usu.edu/wrdc/Files/pdf/ﬁscal_bulletin_1.pdf (accessed July 2006).
Zucker, Lynne. 1987. ‘‘Institutional theories of organization.’’ Annual Review of Sociology 13:443–64.

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