Dimensional Publicness and Serving the Vulnerable: Analyses of Specialized Substance Abuse Treatment Programs

Abstract

The proliferation of market-based public service delivery raises concerns whether the vulnerable are dully served and what mechanisms facilitate to serve them well. Focused on the availability of specialized substance abuse treatment programs for co-occurring, HIV, criminal and pregnant patients, this study adopts the dimensional publicness theory to examine how different dimensions of political authorities facilitate the provision of specialized programs for vulnerable groups. The multilevel analyses indicate that public funding and accreditation are two major dimensions promoting specialized programs. Environmental publicness exercises significant impact, contingent upon statewide policies and facility ownership. Differential effects are found both within and across dimensions, calling for a contingent approach to better understand both the theory and its implications.

Keywords

dimensional publicness vulnerable groups specialized substance abuse treatment programs

Introduction

The proliferation of market-based public service delivery challenges how best to realize public values such as equal protection, access, and affordability (Haque, 2001). Under some circumstances, public organizations are neither the only providers of public services nor the most important ones (for reviews, see Andrews, Boyne, & Walker, 2011; Boyne, 2002) as for-profit and nonprofit counterparts take on more salient roles in fulfilling social responsibilities (Garriga & Melé, 2004; McWilliams & Siegel, 2001) and creating shared values (Porter & Kramer, 2011). The central question remains: What are the possible mechanisms to realize public values? Focused on the availability of specialized substance abuse treatment (hereafter SAT) programs for co-occurring, criminal, HIV, and pregnant patients, the present study attempts to address this central question by adopting the dimensional publicness theory and unfolding how different dimensions of political authorities facilitate the provision of specialized SAT programs for vulnerable groups.

The theory of dimensional publicness stipulates possible mechanisms toward realizing public values. It contends that all organizations are more or less public, subject to different degrees of political authorities (Bozeman, 1987). The publicness concept captures the realized impact of political authorities on individuals and organizations. Extending beyond the sheer focus on public ownership (Aulich, 2011), the theory empowers researchers to explore new frontiers wherein political authorities, defined in a broad fashion, constrain and/or enable organizations/individuals toward delivering public outcomes. Scholarship on publicness has cast attention on selected dimensions such as ownership, public funding, and regulation control (Andrews et al., 2011; Heinrich & Fournier, 2004; Miller & Moulton, 2014; Moulton & Bozeman, 2011). Not just descriptive, the dimensional publicness theory claims the capacity to explain and guide organizational strategies and behaviors (Bozeman & Moulton, 2011; Miller & Moulton, 2014; Nutt & Backoff, 1993). Evidence is building up that dimensional publicness promotes the realization of public values (Bozeman, 2007; Moulton, 2009), such as doing good among private managers (Moulton & Bozeman, 2011), facilitating the provision of public practice services (Miller & Moulton, 2014), and improving organizational performance (Anderson, 2012; Heinrich & Fournier, 2004).

A survey of extant literature suggests that much of scholarly attention is focused on the relationships between publicness (or lack thereof) and indicators such as efficiency and effectiveness (Bøgh Andersen, & Blegvad, 2006; Byrnes, Grosskopf, & Hayes, 1986; Vining & Boardman, 1992), with only a few attending to public value outcomes (e.g., Feeney & Welch, 2012) and even less to how publicness may be tapped to help vulnerable groups (Andrews et al., 2011). In examining the availability of specialized SAT programs for co-occurring, criminal, HIV, and pregnant patients, this study attempts to test how publicness dimensions really make differences in serving vulnerable groups. The issue of service availability is of particular importance not only because substance abuse disorders can hardly be remedied without sufficient access, which may be denied to vulnerable patients due to their lack of resources, but also because substance abuse has significant negative spillover effects to the society (Ettner et al., 2006; Holder, 1998). As such, this study makes positive contribution to understand how social benefits (i.e., access to specialized SAT programs) are distributed for vulnerable groups and what can be effective instruments toward serving the vulnerable better.

Specialized SAT Programs for Vulnerable Groups

Attention on SAT services has been heightened over years as more and more service demands are satisfied by for-profit facilities (Chalk, 1997; Commons, McGuire, & Riordan, 1997; Wheeler & Nahra, 2000). Figure 1a shows percentage changes by facility ownership in the past decade, indicating that for-profit facilities gain rapid growth and public and nonprofit ones wane significantly. One big concern is whether vulnerable individuals are duly served, given their limited capacity to purchase services on markets which increasingly consist of more for-profit facilities (Aday, 1994; Gelberg, Andersen, & Leake, 2000; Jones et al., 2006; Slater, 2001). Particular attention is paid to specialized SAT programs, which represent the state-of-art treatment services and often incorporate services addressing unique demands of different groups to achieve better outcomes (Burnam & Watkins, 2006; Center for Substance Abuse Treatment, 1997; Uziel-Miller & Lyons, 2000). For instance, integrated treatment programs prove more effective in helping the co-occurring patients to reduce substance abuse and attain remission (Burnam & Watkins, 2006; Drake, Mercer-McFadden, Mueser, McHugo, & Bond, 1998). Specialized programs for pregnant women are positively related to decreased use of substance, improved birth outcomes and self-reported health status (Ashley, Marsden, & Brady, 2003; Uziel-Miller & Lyons, 2000).

Figure 1.

Special SAT program availability by ownership.

Figure 1 also reports percentage changes on the availability of specialized SAT programs for vulnerable patients (by facility ownership). The number of specialized SAT programs has been shrinking within public facilities, as evidenced by their constantly negative growth rates (Figure 1b). Among nonprofit facilities, the reduced availability of specialized SAT programs has also been documented for criminal, HIV, and pregnant patients, particularly so in the past few years with the only exception to co-occurring patients (Figure 1c). For-profit organizations show a different pattern, with increased provision of specialized SAT programs for co-occurring patients and pregnant women and decreased availability for criminal and HIV groups (Figure 1d). Given the negative spillover effects from substance abuse disorders (Ettner et al., 2006), the reduced availability of specialized SAT programs for vulnerable groups, particularly among public and nonprofit facilities, represents a serious social concern, questioning whether market-based treatment services will be dully benefiting vulnerable members.

Literature and Research Hypotheses

Publicness captures the continuous variation on different dimensions of political authorities. Although consensus exists on the multidimensional nature of publicness (Andrews et al., 2011; Bozeman, 1987; Merritt, 2014), studies have not yet reached a solid understanding of dimensional specifications, let alone establishing causal links between dimensions and serving the vulnerable. One study (Andrews et al., 2011) presents a synthesized model of publicness, focused on three dimensions as ownership, public funding, and regulation control and contending that higher levels of publicness on three dimensions promote more realization of public values. Latest studies further elaborate the importance of policy environment (Moulton & Bozeman, 2011) and dimensional interactions (Andrews et al., 2011; Miller & Moulton, 2014), alleging that these are complementary to traditional dimensions and together provide strong leverage for fulfilling more public outcomes. This study attempts to integrate empirical dimensions presented in previous literature and propose possible links (Figure 2) between publicness dimensions and serving the vulnerable, with an explicit assumption that the availability of specialized SAT programs represents one important form of public values and counts on political authorities to be well delivered. As an early effort to develop and synthesize different dimensions, this study may fail to capture all-around specifications. Indeed, a line of research has been focused on normative dimensions and argues that institutional approach renders normative components critical and imperative (Moulton, 2009). Extant literature is still exploring how to synthesize normative components with other dimensions (Moulton, 2009; Moulton & Feeney, 2010), and future studies are warranted in this regard.

Figure 2.

Linking dimensional publicness to serving the vulnerable.

Provision of specialized SAT programs is heavily demanded (McLellan, Carise, & Kleber, 2003), yet simultaneously subject to high levels of market failure (Anderson, 2012). Due to possible negative spillover effects, information asymmetry, and asset specialty (Ettner et al., 2006; Holder, 1998), political authorities have been widely wielded to maintain accessibility and quality, among which public funding, accreditation, and state environment attract salient attention. More than three quarters of the funding for SAT services come from public sources, among which roughly half come from state and local government sources other than Medicaid (Buck, 2011). Almost all states have special agencies in charge of SAT services, often resorting to licensing, certification, or credentialing standards to impose control over SAT facilities (Substance Abuse and Mental Health Service Administration, 2015). With different policies, funding availability and political culture, states demonstrate significant variation in how specialized SAT programs can be made available to different groups (Miller & Moulton, 2014). As such, specialized SAT programs are particularly suitable for testing the framework not only because of constant concerns over service availability but also because of substantial public investment that characterizes the wide use of political authorities.

Ownership

By legal constraint, public and nonprofit organizations are prohibited from distributing profits to their owners or managers, whereas for-profit organizations have no such limitations (Rainey, 2009). The legal distinctions across sectors are often well manifested on different missions, structures, and practices (Chalk, 1997; Wheeler & Nahra, 2000), which arguably affect program availability for vulnerable groups. Given their limited resources, it stands to reason that for-profit facilities may be less likely to provide specialized SAT programs for vulnerable members. Indeed, scholars argue for a two-tiered system, within which public and nonprofit SAT facilities serve the vulnerable better than for-profit ones (Wheeler & Nahra, 2000). For-profit units prove less likely to offer initial treatment access and report shortened treatment for a greater proportion of clients unable to pay (Nahra, Alexander, & Pollack, 2009). They are also less likely to accommodate clients with severe financial constraints or those with severe substance abuse disorders. Over time, accessibility differences across sectors have been sustained (Friedmann, Lemon, Stein, & D’Aunno, 2003; Wheeler & Nahra, 2000).

However, a constant reminder in comparing different types of organizations is to attend to their complexity (Rainey & Bozeman, 2000). With the introduction of multiple dimensions of publicness, one study reports that of six major outcome indicators in SAT services, ownership proves significant only in one scenario where, surprisingly, for-profit and nonprofit units are more effective in reducing the number of drugs used than public units (Heinrich & Fournier, 2004). In general, the contribution of ownership to organizational performance is fairly small (Heinrich & Fournier, 2004), and arguments are made that ownership may have less visible influence if other dimensions are well specified (Aulich, 2011; Moulton, 2009). Tentatively,

Hypothesis 1: Public and nonprofit SAT organizations are more likely to offer specialized SAT programs for the vulnerable than for-profit ones.

Public Funding

The pouring of public funding into SAT services has been well justified, though the forms vary substantially. Mandated by congress, federal government spends billions on substance abuse block grants, dedicated to prevention and treatment of substance abuse (Substance Abuse and Mental Health Service Administration, 2015). Medicaid constitutes a major venue to expand access to specialized SAT services, particularly for vulnerable groups. State government general revenues also contribute significantly to SAT services. Regardless of sectors, the pursuit and utilization of public funding presumably brings facilities’ behaviors more or less aligned with public expectations and public values as funding agencies may assert their influences through requirements, expectations, and surveillance. Evidence is found that Medicaid acceptance is significantly related to more treatment (Callahan, Shepard, Beinecke, Larson, & Cavanaugh, 1995; Deck, McFarland, Titus, Laws, & Gabriel, 2000), and more transitional and ancillary services (McBride, Chriqui, Terry-McElrath, & Mulatu, 2012) for disadvantaged individuals. While varying significantly across states, state funding seems to yield similar impacts on serving the vulnerable. For instance, state-financed health plans proved to enhance both access to and quality of SAT services for vulnerable groups (Deck et al., 2000; Schoen, Lyons, Rowland, Davis, & Puleo, 1997; Szilagyi et al., 2004).

Hypothesis 2: Facilities accepting public funding are more likely to provide specialized SAT programs for vulnerable groups.

Accreditation

Accrediting agencies are able to introduce prescriptive, evaluative, and obligatory factors into the practices of SAT facilities (Scott, 2013). Much of substantial impact from accrediting agencies has been documented upon their affiliated members (Edmunds et al., 1997). One study surveyed 108 methadone treatment programs accredited by the Commission on Accreditation of Rehabilitation Facilities (CARF), finding that a significantly higher percentage of programs offer specialized services for women (Wechsberg et al., 2001). Similarly, units accredited by the Joint Commission on Accreditation of Healthcare Organizations (JACHO) provide better access to treatment and ancillary services (Friedmann, Alexander, & D’Aunno, 1999). Arguments are made that organizations spending considerable resources to meet the standards of accrediting agencies demonstrate stronger interest to deliver better services and to realize greater social benefits (Friedmann et al., 1999), for which empirical evidence lends much support. JACHO-accredited units prove more effective in reducing the number of drugs used and in facilitating patients to resume their full-time work (Heinrich & Fournier, 2004). Extant scholarship tends to focus on nationwide professional accrediting agencies, with limited attention paid to state agencies. In reality, nevertheless, the majority of SAT facilities are accredited by state agencies (Heinrich & Fournier, 2004). Although the differences between state and professional accreditations have rarely been addressed, it can stand to reason that the concern for serving the underprivileged should be well expressed and embedded.

Hypothesis 3: Accreditation promotes SAT facilities to deliver more specialized SAT programs for vulnerable groups.

Policy Environment

Organizations tend to resemble each other, especially when isomorphic pressure is high (Dimaggio & Powell, 1983). SAT facilities are no exception (D’Aunno, Sutton, & Price, 1991), with much of pressure coming from state factors. For instance, if facilities are located in states requiring comprehensive substance abuse assessment and other ancillary services, they demonstrate significantly higher odds of offering these services (Chriqui, Terry-McElrath, McBride, & Eidson, 2008). State policies also demonstrate positive impact on offering treatment and ancillary services to drug-abuse pregnant women (Chavkin, Breitbart, Elman, & Wise, 1998). More subtly, evidence is found that state-level environmental factors have ecological impacts on facility practices and that the publicness of policy environments relates closely to public service practices such as offering ancillary services for patients (Miller & Moulton, 2014). Arguably, high levels of environmental publicness capture a greater amount of political authorities, which may be effectively used to promote specialized SAT programs for vulnerable groups.

Hypothesis 4: Facilities subject to higher levels of environmental publicness are more likely to provide specialized SAT programs for vulnerable groups.

Data and Variables

Data for this study were drawn from the 2011 National Survey of Substance Abuse Treatment Services (N-SSATS), which is an annual census survey administered by the Substance Abuse and Mental Health Services Administration. The survey collected information on SAT facilities’ characteristics, services, and activities across states and was publicly available on its official website as well as on interuniversity consortium for political and social research (ICPSR). The dataset provides great opportunities to evaluate the links between publicness dimensions and serving the vulnerable. First, it is a census survey, representing the largest coverage of possible facilities in providing SAT services. Second, the survey design takes into consideration different dimensions of publicness, and for each specific dimension the questionnaires even have multiple embedded measures. Third, specialized SAT services have been given sufficient attention, which allows the study to compare different vulnerable groups. Given that not all facilities provide services for all vulnerable groups, this study limits the sample to those facilities that have admitted specific vulnerable patients within the past 12 months and tests within these facilities, whether specialized SAT programs are available. As such, of total 13,720 facilities, the sample sizes for different vulnerable groups vary substantially, ranging from 8,995 to 10,159. Secondary data were collected from community health status indicators released by Centers for Disease Control and Prevention (CDC), including Medicaid coverage and possible drug use rates across states. The data were combined by using specific state identification information.

Dependent variables were constructed from the survey question: “whether this facility offers a specially designed SAT program or group exclusively for the following types of client at this location.” Focused on vulnerable groups, four dummy variables were created to indicate the presence (or lack) of specialized programs for clients with co-occurring mental and substance abuse disorders (Co-occurring), criminal justice clients (Criminal), persons with HIV/AIDS (HIV), and pregnant or postpartum women (Pregnant). More detailed information about variables can be seen in the appendix.

Publicness Variables

Four main dimensions of publicness were operationalized as independent variables. The survey asked facilities to indicate their ownership, which are classified as public, nonprofit, and for-profit. For public funding, each facility was asked whether they receive government grant, accept Medicaid and state-financed health insurance plans, with three dummy variables (government grant, Medicaid, state-financed plan) being created. The more access a facility has, the more public funding a facility can get. To better understand how accrediting agencies affect facility behaviors, this study incorporated all of the following and separated them into two categories: state accreditation (state substance abuse agency, state mental health department, state department of health, and hospital licensing authority) and professional accreditation (JACHO, CARF, National Committee for Quality Assurance [NCQA], and Council on Accreditation [COA]).

To measure the aggregate impact of different dimensions, this study further constructed three general variables: public funding, state accreditation, and professional accreditation. Two methods were used for the sake of robustness. First, all involved variables were summed and further divided by the number of effective responses. Second, weighting techniques were deployed, with the weights of each variable being 1 minus the mean of the variables. For instance, 87% of facilities were accredited by state substance abuse agency, with the weight being 0.13, whereas 63% of facilities received government grant and yielded the weight 0.37. State (or professional) agencies accreditating more facilities receive less weight as their roles in distinguishing different facilities are smaller and vice versa. Dummy variables were multiplied by their corresponding weights, summed them all, and further divided by the number of effective responses. The weighting techniques capture variable differences to a greater extent than the sum method; however, further analyses show that both sets of variables are highly and significantly correlated, presenting great opportunities for multiple robust checks.

Policy environment contained three variables: collective publicness, resource publicness, and State Medicaid coverage. Collective publicness captured the percentage of SAT facilities that were either public or nonprofit in states, reflecting the degrees of isomorphic pressure as well as ecological differences across states. Resource publicness was operationalized as the average percentage of statewide SAT facilities receiving different sources of public funding, measuring the extent of governmental commitment and of market being affected by public resources. While strongly regulated, states have a certain leeway in setting rules and expectations into their Medicaid programs. State Medicaid coverage not only reflects the general demands for health services among disadvantaged citizens but also captures certain features of service markets and general policy preferences in serving the vulnerable (Barrilleaux & Miller, 1988; Buchanan, Cappelleri, & Ohsfeldt, 1991; Grogan, 1994).

This study incorporated some control variables that are found influential in the extant literature. Facilities located in metropolitan areas prove to offer more specialized SAT programs than those in rural areas, this difference being captured by the location¹ variable (Berkman & Wechsberg, 2007; Friedmann et al., 2003; Heinrich & Fournier, 2004; McBride et al., 2012). Also controlled were the types of clients that facilities serve: percentage of drug-abuse patients and percentage of mentally ill patients, both of which help define the missions and practices of specific SAT facilities.

Model Specifications

When studying issues spanning across different levels of organizations, multilevel modeling technique is the best fit as it allows modeling different levels both independently and interactively and proves more likely to have unbiased estimates (Lynn, Heinrich, & Hill, 2000). Previous studies have demonstrated the applicability and necessity of using such technique (Heinrich & Fournier, 2004; Miller & Moulton, 2014), to which this study follow. The first level of analysis was on SAT facilities, including ownership, public funding, and accreditation as well as facility-level control variables. Level 2 focused on policy environment and dimensional interactions. To better model both policy environment and different interactive dynamics, the random models were specified as follows:

Level 1 : Y_{i j} = β_{0 j} + β_{1 j} o w n e r s h i p_{1 j} + β_{2 j} f u n d i n g_{2 j} + β_{3 j} a c c r e d i t a t i o n_{3 j} + \dots + β_{n j} x_{n j} .

\begin{array}{l} Level 2 : β_{0 j} = γ_{00} + γ_{01} e n v i r o n m e n t a l p u b l i c n e s s_{1 j} + μ_{0 j} . \\ β_{1 j} = γ_{10} + γ_{11} e n v i r o n m e n t a l p u b l i c n e s s_{1 j +} γ_{12} f u n d i n g_{2 j} + γ_{12} a c c r e d i t a t i o n_{2 j} + \dots + μ_{1 j} . \end{array}

For all vulnerable groups, the model outcomes prove significantly different from general linearized models, confirming that state-level factors significantly constrain and/or enable facilities’ behaviors. Further testing shows that random-effect models are preferred to fixed-effect ones, and that in examining the residuals of the first level, the models demonstrate some heterogenic features, entailing the use of clustering variance and other treatments. Overall, the models meet the diagnostic standards and prove well specified. Also, state effects are controlled across the board.

Research Findings

Table 1 presents the descriptive statistics of study variables. Among all facilities, 38% offered specialized SAT programs for co-occurring patients, 27% for criminal, 9% for HIV, and 17% for pregnant women. The availability of specialized programs for the vulnerable seemed low, nevertheless, roughly half facilities at least offered one specialized program for the vulnerable. For-profit SAT facilities gained fast growth over years (Figure 1a) and in 2011 accounted for one third of the population. Nonprofit organizations were dominant in service markets (56%), whereas public ones had very limited visibility (12%).

Table 1.

Descriptive Statistics of Selected Study Variables.

	M	SD
Dependent variables: Specialized programs for
Co-occurring	0.38	0.48
Criminal	0.27	0.45
HIV	0.09	0.28
Pregnant	0.17	0.38
Dimensional publicness
Ownership
Public	0.12	0.32
Nonprofit	0.56	0.50
For-profit	0.32	0.47
Public funding
Government grant	0.63	0.48
Medicaid	0.61	0.49
State-financed plan	0.44	0.50
Weighted public funding	0.77	0.51
Accreditation
State substance abuse agency	0.87	0.34
State mental health department	0.37	0.48
State department of health	0.42	0.49
Hospital licensing authority	0.06	0.23
JACHO	0.16	0.37
CARF	0.24	0.43
NCQA	0.02	0.15
COA	0.05	0.21
Other state agencies	0.06	0.23
State accreditation (weighted)	0.66	0.54
Professional accreditation (weighted)	0.13	0.30
Environmental publicness
Collective publicness (%public and nonprofit)	0.69	0.12
Resource publicness (% receiving public funding)	0.52	0.12
Medicaid coverage in states	0.15	0.04
Interactions
For-Profit × Weighted Funding	0.14	0.34
For-Profit × State Accreditation	0.19	0.41
For-Profit × Professional Accreditation	0.03	0.16
For-Profit × Collective Publicness	0.21	0.31
For-Profit × Resource Publicness	0.16	0.24
For-Profit × Medicaid Coverage in States	0.05	0.07

Note: JACHO = Joint Commission on Accreditation of Healthcare Organizations; CARF = Commission on Accreditation of Rehabilitation Facilities; NCQA = National Committee for Quality Assurance; COA = Council on Accreditation.

Public funding proved essential for SAT services. Sixty-three percent of facilities received government grant for prevention and treatment services, 61% open to Medicaid, and 44% accepted state-financed health insurance plans. Together, 77% of SAT organizations had access to public funding. State substance abuse agencies accredited the majority of SAT facilities (87%), followed by state departments of health (42%), state mental health departments (37%), and hospital licensing authorities (6%). In contrast, nationwide professional organizations had less visible roles (13%). CARF accredited only 24% of SAT facilities, followed by JACHO (16%), COA (5%), and NCQA (2%). Although varying across states, on average, 69% of SAT facilities were either public or nonprofit, and roughly half (52%) received public funding. The average state Medicaid coverage rate was about 15%, consistent with the extant literature (Smith, Gifford, Ellis, Rudowitz, & Synder, 2011).

Table 2 presents the regression outcomes, with major dimensions of publicness serving as explanatory variables. Ownership does not matter except that for-profit facilities offer more specialized SAT programs for pregnant women. One consistent finding is that public funding improves the availability of specialized programs for all vulnerable groups. With the influx of public funding, program availability can be boosted to 13% for co-occurring patients, 8% for criminal, 3% for HIV, and 7% for pregnant women (Figure 3). Given the low offerings of specialized SAT programs, the impact of public funding is substantial.

Table 2.

Multilevel Analyses on Specialized Program Availability to Vulnerable Groups.

Specialized programs for	Co-occurring	Criminal	HIV	Pregnant
Level 1: Facility factors (n)	(9,889)	(9,615)	(10,159)	(8,985)
Ownership (public as reference)
Nonprofit	.27 (.14)	−.03 (.13)	−.06 (.08)	−.02 (.11)
For-profit	.18 (.15)	−.02 (.14)	−.09 (.09)	−.36 (.13)**
Public funding
Weighted public funding	.09 (.01)***	.06 (.01)***	.02 (.01)**	.05 (.01)***
Accreditation
State accreditation	.09 (.01)***	.02 (.01)	.01 (.01)	.03 (.01)**
Professional accreditation	.01 (.02)	−.06 (.02)**	.00 (.01)	−.04 (.02)**
Level 2: Environmental publicness (n)	(50)	(50)	(50)	(50)
Collective publicness	−.02 (.09)	−.22 (.12)	.05 (.05)	−.03 (.06)
Resource publicness	−.01 (.10)	−.10 (.13)	−.12 (.06)**	−.22 (.07)**
State Medicaid coverage	−.51 (.28)	−.18 (.38)	−.07 (.16)	−.27 (.20)**
Dimensional interactions
For-Profit × Weighted Public Funding	.02 (.02)	.02 (.02)	−.02 (.01)	−.01 (.02)
For-Profit × State Accreditation	.06 (.02)**	.03 (.02)	.01 (.01)	.01 (.02)
For-Profit × Professional Accreditation	−.04 (.04)	−.14 (.04)**	−.02 (.02)	−.05 (.03)
For-Profit × Collective Publicness	−.12 (.11)	−.22 (11)**	−.08 (.06)	.20 (.09)**
For-Profit × Resource Publicness	.06 (.11)	.10 (.10)	.08 (.06)	.22 (.09)**
For-Profit × Medicaid Coverage in States	.77 (.34)**	.67 (.33)**	.31 (.20)	.49 (.27)
Control variables
Location	−.03 (.00)***	−.01 (.00)**	−.02 (.00)***	−.02 (.00)***
Hospital affiliation	.01 (.02)	−.11 (.02)***	−.02 (.01)	−.07 (.02)***
Religion affiliation	−.06 (.02)**	.00 (.02)	.01 (.01)	.01 (.02)
Percentage of drug-abuse patients	.00 (.00)***	.00 (.00)***	−.00 (.00)**	−.00 (.00)***
Percentage of mentally ill patients	.00 (.00)***	−.00 (.00)***	.00 (.00)**	.00 (.00)***
Halfway house	−.01 (.02)	−.01 (.02)	.03 (.01)**	.08 (.02)***
Intercept	.00 (.15)	.47 (.16)**	.19 (.09)**	.37 (.12)**
State effects controlled	Yes	Yes	Yes	Yes

p < .05. ***p < .001.

Figure 3.

Marginal effects of public funding and state accreditation.

Accreditation exercises substantial impact on program availability for the vulnerable. Facilities accredited by state authorities prove 22% more likely to offer specialized programs for co-occurring patients, 5% more for criminal (p = .06), and 6% more for pregnant women (Figure 3). Surprisingly, professional accreditations fail to promote specialized SAT programs and demonstrate negative impact on both cases of pregnant women and criminal patients. Environmental publicness shows significant impact on the availability of specialized programs but not necessarily in ways that have been hypothesized (Figure 4). In states where more facilities receive public funding, specialized programs have been reduced for both pregnant women and HIV groups. In those states with more comprehensive Medicaid coverage, specialized programs are less available for co-occurring and pregnant women. Both findings are at odds with the hypothesis contending that more environmental publicness leads to more specialized SAT programs available for the vulnerable. The discrepancy raises a concern why state factors fail to promote more specialized programs for particular groups.

Figure 4.

Marginal effects of environmental publicness.

Multiple dimensional interactions indicate that the impact of environmental publicness varies significantly across ownership. With stronger state accreditations, for-profit SAT facilities offer more specialized programs for co-occurring patients. With wider Medicaid coverage, states see more specialized programs among for-profit ones for both co-occurring and criminal patients (Figure 5). Surprisingly, more professional accreditations in states correspond to less specialized programs among for-profit organizations for criminal clients. In states with more public and nonprofit facilities, for-profit ones offer more specialized programs for pregnant women and less so for criminal patients. When state facilities have more access to public funding, for-profit ones are more committed to serve pregnant women.

Figure 5.

Marginal effects of state Medicaid Coverage × Private.

An assumption is made in Table 2 that different funding sources are homogeneous, and so are accreditations. In reality, different funding may come with different strings and constraints, which produce disparate or even contradictory impact on facilities. To further explore how different funding and accreditations affect the availability of specialized programs for the vulnerable, Table 3 presents more specific regression outcomes. As one can see, receipt of government grant is related to more specialized programs for those in state custody (criminal), posing great public health threat (HIV) and with broad social support (pregnant women). Medicaid acceptance promotes specialized programs for co-occurring patients and pregnant women, consistent with extant literature that Medicaid is related to more access to treatment services (McBride et al., 2012). State-financed insurance plans reinforce service commitment toward co-occurring and criminal patients and deviate significantly from pregnant women.

Table 3.

Multilevel Analyses on Specialized Program Availability to Vulnerable Groups.

Special programs for	Co-occurring	Criminal	HIV	Pregnant
Level 1: Facility factors (n)	(9,889)	(9,615)	(10,159)	(8,985)
Ownership (public as reference)
Nonprofit	.23 (.14)	−.02 (.13)	−.06 (.08)	−.04 (.11)
For-profit	.16 (.15)	−.02 (.15)	−.08 (.09)	−.30 (.13)**
Public funding
Government grant	.01 (.01)	.07 (.01)***	.02 (.01)**	.02 (.01)**
Medicaid	.07 (.01)***	.00 (.01)	.01 (.01)	.07 (.01)***
State-financed plan	.04 (.01)***	.02 (.01)**	.00 (.01)	−.02 (.01)**
Accreditation
State substance abuse agency	−.00 (.01)	.07 (.01)***	.02 (.01)**	.07 (.01)***
State mental health department	.11 (.01)***	.02 (.01)	−.02 (.01)**	−.03 (.01)**
State department of health	.00 (.01)	.01 (.01)	.04 (.01)***	.04 (.01)***
Hospital licensing authority	.04 (.03)	−.04 (.03)	−.03 (.02)**	−.01 (.02)
JACHO	−.00 (.02)	−.05 (.02)***	.01 (.01)	−.01 (.01)
CARF	−.01 (.01)	−.05 (.01)***	.02 (.01)**	.09 (.01)***
NCQA	.20 (.03)***	.07 (.03)**	.05 (.02)**	.01 (.03)
COA	−.05 (.02)**	.05 (.02)**	.02 (.01)	.03 (.02)
Level 2: Environmental publicness (n)	(50)	(50)	(50)	(50)
Collective publicness	.00 (.09)	−.20 (.12)	.04 (.05)	−.06 (.07)
Resource publicness	−.03 (.10)	.08 (.13)	−.11 (.05)**	−.19 (.07)**
State Medicaid coverage	−.52 (.29)**	−.17 (.38)	.12 (.15)	−.10 (.21)
Dimensional interactions
For-Profit × Weighted Public Funding	.02 (.02)	.02 (.02)	−.02 (.01)	−.01 (.02)
For-Profit × State Accreditation	.06 (.02)**	.02 (.02)	.00 (.01)	.01 (.02)
For-Profit × Professional Accreditation	−.04 (.04)	−.13 (.04)**	−.02 (.02)	−.06 (.03)
For-Profit × Collective Publicness	−.14 (.11)	−.17 (.11)	−.08 (.06)	.18 (.09)**
For-Profit × Resource Publicness	.04 (.11)	.09 (.10)	.09 (.06)	.21 (.08)**
For-Profit × Medicaid Coverage in States	.79 (.34)**	.72 (.33)**	.25 (.20)	.26 (.27)
Control variables
Location	−.03 (.00)***	−.01 (.00)**	−.02 (.00)***	−.01 (.00)***
Hospital affiliation	.02 (.02)	−.06 (.02)**	−.00 (.01)	−.05 (.02)**
Religion affiliation	−.05 (.02)**	−.00 (.020)	.00 (.01)	.00 (.02)
Percentage of drug-abuse patients	.00 (.00)**	.00 (.00)***	−.00 (.00)***	−.00 (.00)***
Percentage of mentally ill patients	.00 (.00)***	−.00 (.00)***	.00 (.00)**	.00 (.00)***
Halfway house	.00 (.02)	−.02 (.02)	.02 (.01)**	.08 (.01)***
Intercept	.05 (.15)	.38 (.16)**	.15 (.09)	.26 (.12)**
State effects controlled	Yes	Yes	Yes	Yes

Note. JACHO = Joint Commission on Accreditation of Healthcare Organizations; CARF = Commission on Accreditation of Rehabilitation Facilities; NCQA = National Committee for Quality Assurance; COA = Council on Accreditation.

p < .05. ***p < .001.

The picture is more nuanced when examining the impact of accreditations on specialized programs. Accreditation by state substance abuse agencies facilitates more specialized programs for criminal, HIV, and pregnant women groups but not for co-occurring patients. Those accredited by state mental health departments prove more committed to serve co-occurring patients, but significantly less likely to serve HIV clients and pregnant women. Accreditation by state health departments demonstrates positive impact on HIV clients and pregnant women; nevertheless, those accredited by hospital licensing authorities have less specialized programs for HIV patients. Among professional accreditations, JACHO and CARF reduce specialized programs for criminal patients; CARF promotes more specialized programs for HIV clients and pregnant women. NCQA increases the availability of specialized program for co-occurring, criminal, and HIV patients. COA offers less specialized programs for co-occurring patients but more for the criminal.

Tables 2 and 3 present highly consistent outcomes on control variables. Location matters and facilities located in metropolitan areas proved more likely to offer specialized SAT programs to vulnerable groups than those in rural areas. Patient composition had a significant impact. Facilities admitting more substance abuse patients offered more specialized programs for criminal clients and less for HIV or pregnant women groups, whereas those with more mentally ill patients demonstrate stronger commitment to co-occurring, HIV, and pregnant groups and less commitment to criminal clients. The magnitudes for patient composition, however, are trivial.

Discussion

As more and more SAT services are provided by for-profit facilities, a deep concern is raised whether vulnerable individuals are well served, given their lack of resources to exchange such services in the markets and equally importantly, what mechanisms facilitate the provision of quality programs for the vulnerable (Jones et al., 2006; Slater, 2001). Focused on specialized SAT programs for co-occurring, criminal, HIV, and pregnant women, this inquiry integrates different dimensions of publicness and explores how each dimension as well as dimensional interactions shapes facilities to deliver services. The findings suggest that political authorities are manifested in multiple dimensions, though public funding and accreditations seem most salient. Environmental publicness exercises significant impact on SAT facilities, contingent upon both statewide policies and facility ownership. For instance, in states with wider Medicaid coverage, less specialized programs are available for co-occurring, but for-profit facilities are more committed to serving co-occurring and criminal clients. When more facilities receive public funding in states, specialized programs are reduced for HIVs and pregnant women, but for-profit facilities offer more for pregnant women. Further analyses suggest that even within the same dimension, it is likely that different components take on different parameters in serving differential vulnerable groups. The theory of dimensional publicness provides an important framework to investigate how political authorities affect the delivery of public services; in the meantime, the contingent approach is imperative to better understand and design specific policies.

Public Funding

Facilities receiving public funding are more committed to offer specialized programs for the vulnerable, the pattern being consistent and robust across the board (Table 2). Noticeable is that different sources of public funding result in differential impact (Table 3). Governmental grant promotes more specialized programs for pregnant women, criminal and HIV groups, whereas Medicaid increases availability for co-occurring patients and pregnant women. State-financed health insurance helps offer more specialized programs for co-occurring and criminal patients and less for pregnant women. Given that Medicaid costs have been largely reimbursed by federal government (Smith et al., 2011) and its coverage is comprehensive on pregnant women and co-occurring patients, government grant and state-financed health insurance plans seem to have picked up different groups or serve in supplementary roles. Evidence suggests that states shoulder responsibilities for health care costs incurred by criminal justice system (Dubose, 2011), to which both state-financed health insurance plans and government funding prove dedicated. For the HIV group, due to their special risks of transmission, the Ryan White Program (a stand-alone government program) provides care and support services for roughly half population living with HIVs each year, and evidence points out that the program promotes quality services for HIV patients (Sullivan et al., 2008).

In general, different sources of public funding seem to provide a good coverage for all vulnerable groups. In a market with increasingly more for-profit facilities, public funding provides good safety nets for the disadvantaged. However, a concern is raised whether different vulnerable groups have equal access to specialized programs. After all, different public funding often comes with different rules and requirements and may treat some groups more favorably than others. Studies have documented significant variations across states in terms of their policy preferences and practices, which also likely yield substantial interjurisdictional inequity among the vulnerable (Chriqui et al., 2008). The concern is important as vulnerable groups are short of resources or power to defend their equal rights and without assistance from public funding, their substance abuse challenges can hardly be remedied and often produce negative spillover effects on the society.

Accreditation

The conflicting patterns among accrediting agencies raise some puzzles. One would assume that accrediting agencies, by setting up standards and imposing regulatory rules (D’Aunno, 2006; Scott, 2013), all promote the delivery of specialized programs to vulnerable groups. After all, to serve the underserved is one of core values that have been embraced in their missions, particularly among state accrediting agencies (Estrube, Hettenbach, Arthur, & Messina, 2010). The findings show that not all accrediting organizations are equally committed to all underserved groups. The differences may reflect a few possible scenarios. First, accrediting agencies carry different kinds of values and missions (D’Aunno et al., 1991; Scott, 2013), which often prioritize some groups over others. For instance, departments of mental health naturally place more emphasis on those with mental disorders (co-occurring patients), often at the expense of other groups (HIV and pregnant women). State departments of health may be particularly attentive to groups with public health threats (HIV groups) or those carrying broad social support and impact (pregnant women). Among professional accrediting agencies, similar patterns are found that CARF members seem more committed to HIV patients and pregnant women, whereas NCQA members prove more dedicated to all vulnerable groups except pregnant women. Second, intertwined with different values and missions, accrediting organizations may play strategically in responses to varying market situations, presumably more so among professional accreditation agencies. To expand their customer bases and enhance their legitimacy, accrediting agencies may be more focused on service availability to some groups while excluding them to others. Future studies are required to see why different accrediting organizations position themselves in different fashions and how their positions are related to the delivery of public outcomes.

Environmental Publicness

State-level factors shape facilities’ commitment to serving the vulnerable. When more facilities receive public funding in states, less specialized programs are available for HIV clients and pregnant women. In states with wider Medicaid coverage, less specialized programs exist for co-occurring patients. Both contradict with the findings that more public funding leads to more specialized programs for the vulnerable. Different dynamics may be at work. To control cost and expand access (e.g., see Galanter, Keller, Dermatis, & Egelko, 2000), public funding is often used with strong constraints on service options and costs. More facilities receiving public funding indicate that states have stronger service demands, and that public resources are spread thinner. Given that specialized programs are costly, states with more facilities counting on public funding may be less able or willing to invest in specialized programs for HIVs and pregnant women groups.

One study proves that states spending more on Medicaid are those who need it most but can afford it least (Barrilleaux & Miller, 1988). The cost containment efforts in health care have been a consistent trend (Davis, Anderson, Rowland, & Steinberg, 1990; Weisbrod, 1991), which often places no priority on specialized programs relative to general services. This finding questions the positive and universal linkages between environmental publicness and public values, suggesting that potential trade-offs may exist between program availability and other public values such as cost containment and effectiveness, and that the impact of environmental publicness needs to be scrutinized carefully, particularly when resources are constrained and service demands are acute.

Dimensional Interactions

The impact of environmental publicness varies greatly when interacting with facility ownership. In states where more facilities are accredited by state agencies, for-profit facilities prove more likely to offer specialized programs for co-occurring patients. Plausibly, with stronger state control, for-profit organizations are subject to higher isomorphic pressure (Dimaggio & Powell, 1983) in serving co-occurring patients. Given the wide discretion for being members of professional accreditation agencies and the custody status of criminal patients (Dubose, 2011), it is not a surprise that for-profit facilities show lower commitment to serve the criminals if more state facilities are accredited by professional accreditation agencies.

In states with higher levels of collective publicness or resource publicness, for-profit organizations prove more committed to serve pregnant women. In states with wider Medicaid coverage, for-profit organizations offer more specialized programs for both co-occurring and criminal patients. The positive commitment among for-profit facilities is at odds with the previous findings that states with more public funding or wider Medicaid coverage reduce specialized programs for the vulnerable. The reconciliation of these findings rests on different strategies across ownership. For-profit organizations are endowed with more flexibility and stronger incentives toward high profits (Boyne, 2002). In states where specialized programs are less available due to higher levels of resource publicness and/or wider Medicaid coverage, opportunities are presented for for-profit organizations to pin down different market niches and to seek for more profits, particularly considering that specialized programs are more expensive on the service markets. This argument for different strategies among for-profit organizations resonates well in extant literature. One study (Miller & Moulton, 2014) finds out that for-profit organizations are more likely to engage in public service practices if states are characterized by higher levels of environmental publicness, and that for-profit organizations tend to pay more attention to financial benefits/loss in providing these practices.

Conclusion

The theory of dimensional publicness offers an important framework with which the realization of public values can be explored by investigating different dimensions of political authorities (Andrews et al., 2011; Aulich, 2011; Bozeman & Moulton, 2011). This study finds, though all dimensions matter, each dimension demonstrates differential impact and within each specific dimension, different components make differences too. The interactions between dimensions also prove nuanced and dynamic. Thus, a contingent approach is rendered necessary in applying and interpreting the dimensional publicness theory.

Departing from previous studies comparing different kinds of ownership, this study contends that ownership matters in context-specific ways. The important question therefore is not “what types of ownership work best,” but “what aspects of organizations work, in what context and for whom” (Heinrich & Fournier, 2004). Public funding facilitates the provision of specialized programs for the vulnerable, yet public funding seems not well integrated as different sources of funding embody disparate preferences for vulnerable groups (Buck, 2011). While in total, public funding seems to provide a good coverage for vulnerable groups, it is highly likely that due to different restrictions and requirements, vulnerable groups have differential access to quality services. Given that public funding is often the last resort vulnerable groups can have, unequal access presents potential hazards not only for the vulnerable but also for communities and societies. Careful examination of how different funding can be seamlessly integrated therefore should be on the policy agenda.

The existing fragmented accreditation system presents a serious challenge. This study represents an early effort to examine how state accreditations work in a web of agencies characterized by different and often conflicting missions, and how state and professional accreditations may work differently. Noticeable is that facilities, regardless of their ownership, are empowered with certain discretion to respond strategically (Miller & Moulton, 2014; Uziel-Miller & Lyons, 2000), so are accreditation agencies. Currently, understanding of strategic behaviors among those accrediting agencies and those being accredited is very limited, with little practical knowledge being offered for practitioners in the SAT field. Further studies should reveal how conflicting preferences across agencies can be tuned, and how facilities and accrediting agencies respond to each other to fulfill different public values.

The importance of environmental publicness notwithstanding, this study has to acknowledge that program availability is just one expression of public values and often has to compete with other public values in shaping possible outcomes (Barrilleaux & Miller, 1988; Edmunds et al., 1997). Facilities with higher levels of environmental publicness fail to promote more specialized programs for vulnerable groups, suggesting that program availability may not be the top priority in state policy designs. With limited resources in states and strong demands, availability of specialized programs for the vulnerable may have to be balanced with other considerations such as cost containment, effectiveness and availability of funding (Ettner et al., 2006; Holder, 1998). Future studies are warranted to explore how program availability interacts with other public values and how the balanced preferences can be well designed into different policies.

Different strategic behaviors are not only embedded in facilities, funding choices, and accreditation agencies but also witnessed in dimensional interactions. Given the rapid growth of for-profit facilities (Anderson, 2012), study of their behaviors is particularly warranted as for-profit facilities are filling up more service demands and their behaviors seem different than public and nonprofit (Andrews et al., 2011; Miller & Moulton, 2014). For instance, when the levels of environmental publicness are high, for-profit facilities seem to find better niches in serving more co-occurring and pregnant patients. Their strategic choices can be shaped by market situations, reimbursement policies, and regulatory expectation and others, for which more understanding is important and necessary.

This study attempts to test the linkages between publicness dimensions and realization of public values. It is important to note that the analysis is limited to one policy field at one point in time, and that public values are limited to the availability of specialized programs. Future studies can benefit greatly from longitudinal analyses to sort out whether causal dynamics are as predicted. Equally important, more policy fields should be tested to see the range of effectiveness of the theory and to elaborate how the theories can be more predictable under different conditions. Nevertheless, this study sheds lights on an important form of public values that are not well attended to and offers contribution to build and test links between synthesized publicness dimensions and realization of public values. In uncovering existing patterns and potential challenges, the findings may help both policy makers and practitioners to best map the SAT field and if possible, to make necessary reforms.

Footnotes

Appendix

Variables and Constructs.

Dependent variables
Co-occurring	Indicate whether this facility offers a specially designed substance abuse treatment program or group exclusively for clients with co-occurring mental and substance abuse disorders at this location. Dummy variable, with 1 being yes and 0 otherwise
Criminal	Indicate whether this facility offers a specially designed substance abuse treatment program or group exclusively for criminal justice clients (other than driving under the influence [DUI]/ driving while intoxicated [DWI]) at this location. Dummy variable, with 1 being yes and 0 otherwise
HIV	Indicate whether this facility offers a specially designed substance abuse treatment program or group exclusively for persons with HIV or AIDS at this location. Dummy variable, with 1 being yes and 0 otherwise
Pregnant	Indicate whether this facility offers a specially designed substance abuse treatment program or group exclusively for clients with pregnant or postpartum women at this location. Dummy variable, with 1 being yes and 0 otherwise
Independent variables
Ownership
Public	Is this facility operated by federal, state, or local government? Dummy variable
Nonprofit	Is this facility operated by a private nonprofit organization? Dummy variable
For-profit	Is this facility operated by a private for-profit organization? Dummy variable
Public funding
Government grant	Does this facility receive any funding or grants from the federal, state, or local governments to support its substance abuse treatment programs? Dummy variable
Medicaid	Is Medicaid accepted by this facility for substance abuse treatment?
State-financed plan	Is a state-financed health insurance plan other than Medicaid accepted by this facility for substance abuse treatment?
Accreditation
State substance abuse agency	Is this facility or program licensed, certified, or accredited to provide substance abuse services by state substance abuse agency?
State mental health department	Is this facility or program licensed, certified, or accredited to provide substance abuse services by state mental health department?
State department of health	Is this facility or program licensed, certified, or accredited to provide substance abuse services by state department of health?
Hospital licensing authority	Is this facility or program licensed, certified, or accredited to provide substance abuse services by hospital licensing authority?
JACHO	Is this facility or program licensed, certified, or accredited to provide substance abuse services by the joint commission?
CARF	Is this facility or program licensed, certified, or accredited to provide substance abuse services by commission on accreditation or rehabilitation facilities?
NCQA	Is this facility or program licensed, certified, or accredited to provide substance abuse services by National Committee for Quality Assurance?
COA	Is this facility or program licensed, certified, or accredited to provide substance abuse services by Council on Accreditation?
Policy environment
Collective publicness	Among all providing specialized substance abuse treatment facilities, what percentage of facilities is either public or nonprofit?
Resource publicness	Among all providing specialized substance abuse treatment facilities, to what extent facilities are open to public funding? The variable is operationalized as the average access to three different sources of public funding
Medicaid coverage in states	Data from community health status indicators released by CDC

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Notes

Author Biography

Xuhong Su’s research interest has been focused on themes in public administraiton field, with particular attention toward HR policies and analysis of public service delivery.

References

Aday

L. A.

(1994). Health status of vulnerable populations. Annual Review of Public Health, 15, 487-509.

Anderson

(2012). Public, private, neither, both? Publicness theory and the analysis of healthcare organisations. Social Science & Medicine, 74, 313-322.

Andrews

Boyne

G. A.

Walker

R. M.

(2011). Dimensions of publicness and organizational performance: A review of the evidence. Journal of Public Administration Research and Theory, 21(Suppl. 3), i301-i319.

Ashley

O. S.

Marsden

M. E.

Brady

T. M.

(2003). Effectiveness of substance abuse treatment programming for women: A review. The American Journal of Drug and Alcohol Abuse, 29, 19-53.

Aulich

(2011). It’s not ownership that matters: It’s publicness. Policy Studies, 32, 199-213.

Barrilleaux

C. J.

Miller

M. E.

(1988). The political economy of state Medicaid policy. American Political Science Review, 82, 1089-1107.

Berkman

N. D.

Wechsberg

W. M.

(2007). Access to treatment-related and support services in methadone treatment programs. Journal of Substance Abuse Treatment, 32, 97-104.

Bøgh Andersen

Blegvad

. (2006). Does ownership matter for the delivery of professionalized public services? Cost-efficiency and effectiveness in private and public dental care for children in Denmark. Public Administration, 84, 147-164.

Boyne

G. A.

(2002). Public and private management: What’s the difference? Journal of Management Studies, 39, 97-122.

10.

Bozeman

(1987). All organizations are public: Bridging public and private organization theories. San Francisco, CA: Jossey-Bass.

11.

Bozeman

(2007). Public values and public interest: Counterbalancing economic individualism. Washington, DC: Georgetown University Press.

12.

Bozeman

Moulton

(2011). Integrative publicness: A framework for public management strategy and performance. Journal of Public Administration Research and Theory, 21(Suppl. 3), i363-i380.

13.

Buchanan

R. J.

Cappelleri

J. C.

Ohsfeldt

R. L.

(1991). The social environment and Medicaid expenditures: Factors influencing the level of state Medicaid spending. Public Administration Review, 51, 67-73.

14.

Buck

J. A.

(2011). The looming expansion and transformation of public substance abuse treatment under the Affordable Care Act. Health Affairs, 30, 1402-1410.

15.

Burnam

M. A.

Watkins

K. E.

(2006). Substance abuse with mental disorders: Specialized public systems and integrated care. Health Affairs, 25, 648-658.

16.

Byrnes

Grosskopf

Hayes

(1986). Efficiency and ownership: Further evidence. The Review of Economics and Statistics, 68, 337-341.

17.

Callahan

J. J.

Shepard

D. S.

Beinecke

R. H.

Larson

M. J.

Cavanaugh

(1995). Mental health/substance abuse treatment in managed care: The Massachusetts Medicaid experience. Health Affairs, 14, 173-184.

18.

Center for Substance Abuse Treatment. (1997). Specialized substance abuse treatment programs: A guide to substance abuse services for primary care clinicians (Vol. Treatment Improvement Protocol (TIP) Series, No. 24). Rockville, MD: Substance Abuse and Mental Health Services Administration.

19.

Chalk

(1997). Privatizing public mental health and substance abuse services: Issues, opportunities, and challenges. Quality Management in Healthcare, 5(2), 55-64.

20.

Chavkin

Breitbart

Elman

Wise

P. H.

(1998). National survey of the states: Policies and practices regarding drug-using pregnant women. American Journal of Public Health, 88, 117-119.

21.

Chriqui

J. F.

Terry-McElrath

McBride

D. C.

Eidson

S. S.

(2008). State policies matter: The case of outpatient drug treatment program practices. Journal of Substance Abuse Treatment, 35, 13-21.

22.

Commons

McGuire

T. G.

Riordan

M. H.

(1997). Performance contracting for substance abuse treatment. Health Services Research, 32, 631-650.

23.

D’Aunno

(2006). The role of organization and management in substance abuse treatment: Review and roadmap. Journal of Substance Abuse Treatment, 31, 221-233.

24.

D’Aunno

Sutton

R. I.

Price

R. H.

(1991). Isomorphism and external support in conflicting institutional environments: A study of drug abuse treatment units. Academy of Management Journal, 34, 636-661.

25.

Davis

Anderson

G. F.

Rowland

Steinberg

E. P.

(1990). Health care cost containment. Baltimore, MD: Johns Hopkins University Press.

26.

Deck

D. D.

McFarland

B. H.

Titus

J. M.

Laws

K. E.

Gabriel

R. M.

(2000). Access to substance abuse treatment services under the Oregon Health Plan. The Journal of the American Medical Association, 284, 2093-2099.

27.

Dimaggio

P. J.

Powell

W. W.

(1983). The iron cage revisited: Institutional isomorphism and collective rationality in organizational fields. American Sociological Review, 48, 147-160.

28.

Drake

R. E.

Mercer-McFadden

Mueser

K. T.

McHugo

G. J.

Bond

G. R.

(1998). Review of integrated mental health and substance abuse treatment for patients with dual disorders. Schizophrenia Bulletin, 24, 589-608.

29.

Dubose

(2011). Medicaid expansion and the local criminal justice system. American Jails, 25, 8-14.

30.

Edmunds

Frank

Hogan

McCarty

Robinson-Beale

Weisner

(Eds.). (1997). Managing managed care: Quality improvements in behavioral health: Summary. Washington, DC: National Academy Press.

31.

Estrube

Hettenbach

Arthur

Messina

(2010). Service delivery for vulnerable populations: New directions in behavioral health. New York, NY: Springer.

32.

Ettner

S. L.

Huang

Evans

Rose Ash

Hardy

Jourabchi

Hser

Y. I.

(2006). Benefit-cost in the California treatment outcome project: Does substance abuse treatment “pay for itself”? Health Services Research, 41, 192-213.

33.

Feeney

M. K.

Welch

E. W.

(2012). Realized publicness at public and private research universities. Public Administration Review, 72, 272-284.

34.

Friedmann

P. D.

Alexander

J. A.

D’Aunno

T. A.

(1999). Organizational correlates of access to primary care and mental health services in drug abuse treatment units. Journal of Substance Abuse Treatment, 16, 71-80.

35.

Friedmann

P. D.

Lemon

S. C.

Stein

M. D.

D’Aunno

T. A.

(2003). Accessibility of addiction treatment: Results from a national survey of outpatient substance abuse treatment organizations. Health Services Research, 38, 887-903.

36.

Galanter

Keller

D. S.

Dermatis

Egelko

(2000). The impact of managed care on substance abuse treatment: A report of the American Society of Addiction Medicine. Journal of Addictive Diseases, 19(3), 13-34.

37.

Garriga

Melé

(2004). Corporate social responsibility theories: Mapping the territory. Journal of Business Ethics, 53(1-2), 51-71.

38.

Gelberg

Andersen

R. M.

Leake

B. D.

(2000). The Behavioral Model for Vulnerable Populations: Application to medical care use and outcomes for homeless people. Health Services Research, 34, 1273-1302.

39.

Grogan

C. M.

(1994). Political-economic factors influencing state Medicaid policy. Political Research Quarterly, 47, 589-622.

40.

Haque

M. S.

(2001). The diminishing publicness of public service under the current mode of governance. Public Administration Review, 61, 65-82.

41.

Heinrich

C. J.

Fournier

(2004). Dimensions of publicness and performance in substance abuse treatment organizations. Journal of Policy Analysis and Management, 23, 49-70.

42.

Holder

H. D.

(1998). Cost benefits of substance abuse treatment: An overview of results from alcohol and drug abuse. The Journal of Mental Health Policy and Economics, 1, 23-29.

43.

Jones

Sumnall

Witty

Wareing

McVeigh

Bellis

(2006). A review of community-based interventions to reduce substance misuse among vulnerable and disadvantaged young people. London, England: National Institute for Health and Clinical Excellence.

44.

Lynn

L. E.

Heinrich

C. J.

Hill

C. J.

(2000). Studying governance and public management: Challenges and prospects. Journal of Public Administration Research and Theory, 10, 233-262.

45.

McBride

D. C.

Chriqui

J. F.

Terry-McElrath

Y. M.

Mulatu

M. S.

(2012). Drug treatment program ownership, Medicaid acceptance, and service provision. Journal of Substance Abuse Treatment, 42, 116-124.

46.

McLellan

A. T.

Carise

Kleber

H. D.

(2003). Can the national addiction treatment infrastructure support the public’s demand for quality care. Journal of Substance Abuse Treatment, 25, 117-121.

47.

McWilliams

Siegel

(2001). Corporate social responsibility: A theory of the firm perspective. Academy of Management Review, 26, 117-127.

48.

Merritt

(2014). Specifying and testing a multi-dimensional model of publicness: An analysis of mental health and substance abuse treatment facilities (Doctoral dissertation). University of Kansas, Lawrence, KS.

49.

Miller

S. M.

Moulton

(2014). Publicness in policy environments: A multilevel analysis of substance abuse treatment services. Journal of Public Administration Research and Theory, 24, 553-589.

50.

Moulton

(2009). Putting together the publicness puzzle: A framework for realized publicness. Public Administration Review, 69, 889-900.

51.

Moulton

Bozeman

(2011). The publicness of policy environments: An evaluation of subprime mortgage lending. Journal of Public Administration Research and Theory, 21, 87-115.

52.

Moulton

Feeney

M. K.

(2010). Public service in the private sector: Private loan originator participation in a public mortgage program. Journal of Public Administration Research and Theory, 21, 547-572.

53.

Nahra

T. A.

Alexander

Pollack

(2009). Influence of ownership on access in outpatient substance abuse treatment. Journal of Substance Abuse Treatment, 36, 355-365.

54.

Nutt

P. C.

Backoff

R. W.

(1993). Organizational publicness and its implications for strategic management. Journal of Public Administration Research and Theory, 3, 209-231.

55.

Porter

M. E.

Kramer

M. R.

(2011). The big idea: Creating shared value. Harvard Business Review, 89(1/2), 62-77.

56.

Rainey

H. G.

(2009). Understanding and managing public organizations (4th ed.). San Francisco, CA: Jossey-Bass.

57.

Rainey

H. G.

Bozeman

(2000). Comparing public and private organizations: Empirical research and the power of the a priori. Journal of Public Administration Research and Theory, 10, 447-470.

58.

Schoen

Lyons

Rowland

Davis

Puleo

(1997). Insurance matters for low-income adults: Results from a five-state survey. Health Affairs, 16, 163-171.

59.

Scott

W. W. R.

(2013). Institutions and organizations: Ideas, interests, and identities. Thousand Oaks, CA: Sage.

60.

Slater

(2001). Preventing the abuse of vulnerable adults: Social policy and research. Journal of Social Policy, 30, 673-684.

61.

Smith

Gifford

Ellis

Rudowitz

Synder

(2011). Moving ahead amid fiscal challenges: A look at Medicaid spending, coverage and policy trends. Washington, DC: Kaiser Family Foundation.

62.

Substance Abuse and Mental Health Service Administration. (2015). Funding and characteristics of single state agencies for substance abuse services and state mental health agencies, 2013 (HHS Pub. No. [SMA] 15-4926). Rockville, MD: Substance Abuse and Mental Health Services Administration.

63.

Sullivan

P. S.

Denniston

Mokotoff

Buskin

Broyles

McNaghten

(2008). Quality of care for HIV infection provided by Ryan White Program-supported versus Non-Ryan White Program-supported facilities. PLoS ONE, 3(9), e3250.

64.

Szilagyi

P. G.

Dick

A. W.

Klein

J. D.

Shone

L. P.

Zwanziger

McInerny

(2004). Improved access and quality of care after enrollment in the New York State Children’s Health Insurance Program (SCHIP). Pediatrics, 113, e395-e404.

65.

Uziel-Miller

N. D.

Lyons

J. S.

(2000). Specialized substance abuse treatment for women and their children: An analysis of program design. Journal of Substance Abuse Treatment, 19, 355-367.

66.

Vining

A. R.

Boardman

A. E.

(1992). Ownership versus competition: Efficiency in public enterprise. Public Choice, 73, 205-239.

67.

Wechsberg

Suerken

Crum

Berkman

Kasten

Fulmer

. . . Stanton

(2001, October). Availability of special services for women in methadone treatment: Results from a national study. Paper presented at the 129th Annual Meeting and Exposition of the American Public Health Association, Atlanta, GA.

68.

Weisbrod

B. A.

(1991). The health care quadrilemma: An essay on technological change, insurance, quality of care, and cost containment. Journal of Economic Literature, 29, 523-552.

69.

Wheeler

J. C.

Nahra

(2000). Private and public ownership in outpatient substance abuse treatment: Do we have a two-tiered system? Administration and Policy in Mental Health and Mental Health Services Research, 27, 197-209.