RAND Health Quarterly, 2025; 13(1):1
RAND Health Quarterly is an online-only journal dedicated to showcasing the breadth of health research and policy analysis conducted RAND-wide.
More in this issueEvidence-based practices (EBPs) integrate clinical experience, recipient preferences, and the best available research evidence into best practices for health and human services. The use of EBPs plays an important role in delivering high-quality substance use services that improve youth outcomes. Yet there are many challenges to EBP implementation. During a March 2025 roundtable that was hosted at the Joint Meeting on Youth Prevention, Treatment, and Recovery national conference, policy actors with key roles in supporting state service systems discussed how to support the implementation of EBPs for youth substance use equitably and at scale. State service systems include a network of community-based prevention, treatment, and recovery programs for youth substance use that are primarily supported by public funds.
Main topics of discussion included the role of federal and state policymakers in supporting the use of EBPs, opportunities and challenges in implementing and sustaining EBPs, and opportunities for partnerships to encourage the use of EBPs. Given the complexity of the topic, partnerships were viewed as key to successful progress in achieving policy action that supports EBP use. These proceedings should be of interest to federal, state, and local policymakers and other related groups, such as policy advocates, youth and their caregivers, and other individuals who are interested in improving the quality of substance use services.
On Wednesday, March 19, 2025, the Joint Meeting on Youth Prevention, Treatment, and Recovery national conference hosted a roundtable titled “Aligning Policy to Support Evidence-Based Youth Substance Use Services Equitably and at Scale.” This roundtable brought together policy actors who had key roles in supporting state service systems for youth with substance use problems. Funded primarily through public sources, state service systems include a network of community-based prevention, treatment, and recovery programs for youth substance use. State perspectives were represented by Marianne Gibson from the National Governors Association (NGA), Charlie Severance-Medaris from the National Conference of State Legislatures, and Hannah Maniates from the National Association of Medicaid Directors (NAMD). These representatives had expertise and experience related specifically to services for youth substance use (including policies, programs, and practices) and the use of evidence-based practices (EBPs) within those services. The session was moderated by two research experts who specialize in substance use services policy and systems: Alex Dopp from RAND and Lora Passetti from Chestnut Health Systems.
The panel discussion focused on EBPs for substance use in youth. Generally, EBPs integrate clinical experience, recipient preferences, and the best available research evidence into best practices for health and human services. Examples of EBPs for substance use in youth include screening and referral, motivational interviewing, behavioral therapies, family-based services, and continuing care (Welsh et al., 2025). During the panel discussion, we explicitly acknowledged that the term evidence-based can include different levels of evidentiary strength and sources of evidence, such as community-defined evidence derived from lived experience and formal research evidence. Panelists responded to questions from the moderators and audience members, which covered several major topics about policies that support the use of EBPs in youth substance use services. Summaries of the discussion are organized by topic in the subsequent sections.
Each of the panelists was asked how federal and state policymakers could support the use of EBPs in youth substance use services. The discussion focused on the following three main ways to incorporate EBPs into policy design and implementation: legislation, budget priorities, and Medicaid policy.
Federal and state policymakers could use legislation as a vehicle to promote policies focused on the implementation of EBPs. Panelists described problematic substance use as a bipartisan issue that needs individuals to come together at the federal, state, and local levels. For example, legislation created at the federal level affects states, and state lawmakers are interested in making sure that programs implemented with taxpayer money have the intended impact.
As the voice of the state, governors have important roles in making sure that state and federal resources for policies, programs, and practices are used responsibly and effectively, as well as ensuring that the best EBPs are implemented. Governors set policy priorities and develop a draft state budget for the legislature to consider each year. They also appoint state cabinet officials, who help carry out the governors' visions and missions.
Anything that requires a statutory change in a state goes through the state legislature. Therefore, legislation that requires or incentivizes the implementation of EBPs would have to be approved by the state legislature. Legislators work with governors to create statutory change. Legislatures also make up the oversight and accounting branch of government and are, therefore, very interested in the accounting of various funding sources and allocation of expenditures. Anything that requires the allocation of state funds must be approved by state legislators and signed by the governor. Both governors and state lawmakers could convene all the needed sources of input on legislation at the state and local levels, as well as engage with federal partners to develop a legislative strategy related to EBPs.
Determining how taxpayer money is spent to address youth substance use through EBPs requires sustained efforts at multiple levels (prevention, treatment, recovery, and ongoing research). Federal and state policymakers must collaborate to ensure that youth services are prioritized and that systems are in place to identify and intervene proactively when youth exhibit risk factors or other signs suggesting early initiation of substance use.
Governors and their cabinet officials play a crucial role in determining funding priorities within state budgets; however, adolescent services continue to receive only a fraction of the resources that are allocated to adult treatment programs. This funding disparity makes it increasingly difficult for states to provide adequate care for youth substance use.
When budget cuts occur—such as those that took place after coronavirus disease 2019 (COVID-19) relief funds were depleted—states face difficult decisions regarding which services to sustain and which recipient groups to prioritize. With mounting pressure to secure new funding sources, states must carefully assess whether critical programs can continue or if some will sunset. To ensure the long-term success of youth substance use services, policymakers will need to commit to exploring sustainable funding mechanisms and policies.
Panelists stated that Medicaid was the single largest payer for mental health and substance use services in the United States. One-quarter of people are covered, and half of all people enrolled in this coverage are children and youth. Medicaid tends to lead health care payers in covering new services—with other payers often following its example. For instance, Medicaid was the first payer to cover peer support services. Therefore, alignment between EBP delivery and available Medicaid funding is an important foundation for scaling and sustaining effective services.
Medicaid's funding and benefit structure is shared between the state and federal governments. The federal government sets the minimum requirements that groups must meet to be eligible for the services and benefits provided. However, states also make coverage decisions based on their specific funds, priorities, and needs, which results in wide variation in coverage across states. Therefore, many people could influence Medicaid policy related to EBPs, including representatives of the federal government, state governors, state legislators, service providers, and people with lived experience.
Panelists were prompted to discuss opportunities and challenges associated with implementing and sustaining EBPs in youth substance use services. Common themes from this discussion included increasing access to care, addressing workforce challenges, influencing budgets, accessing opioid settlement funds, and integrating substance use services with mental health and medical services.
One potential area of opportunity for implementing EBPs in youth substance use services is through the incorporation of EBPs into efforts to increase service access. EBPs that help build new continua of services, youth reentry programs, digital interventions, and crisis-response systems (such as 988 and mobile crisis response) were mentioned. Panelists mentioned California as an example of using digital interventions to scale up access to specific prevention services for mental health and substance use problems.
Panelists stated that workforce issues present both challenges and opportunities. Youth services, in particular, face workforce shortages and have difficulties attracting and retaining staff. This has been a key focus for legislators, and solutions remain difficult to identify. The National Conference of State Legislatures (2025) launched a public database that tracks health care workforce bills that have been introduced in states across the country because legislators are interested in programs that have been shown to be successful. Opportunities in this area included increasing reimbursement rates for services to better match the costs involved and expanding Medicaid coverage to other service types. For example, Utah created a new behavioral health technician certification to help meet demand. Some states are evaluating enhanced payment rates and pay-for-performance models to better incentivize EBP implementation and attract workers through increased salaries.
Federal and state budgets present additional challenges and opportunities for supporting EBP implementation. The federal government recently passed legislation that reduces the size and scope of Medicaid, which will create a far more restrictive fiscal environment (Association of State and Territorial Health Officials, 2025). Additionally, some practices have been described as evidence-based without sufficient research evidence; at the same time, states do not necessarily have the resources to fund evaluation studies and need support to determine the effectiveness of such practices. Thus, governors and legislators have had to make complex decisions about funding and want to know whether their investments are effective. Additionally, they may need to be more creative around financing sources to invest in youth. One example of a state that created opportunities for EBPs to address substance use among youth was Maine: The Maine Department of Education implemented an EBP called Building Assets, Reducing Risks, which was described as a strengths-based universal prevention program focused on building resiliency among high school students. This program was shown to reduce substance use, as well as suicidal ideation, and has been scaled to 71 schools across the state.
Panelists identified opioid settlement funds as a major opportunity for accessing money to implement EBPs in youth substance use services, particularly in services focused on prevention. States are creating advisory committees to determine how funds are spent, and some committees are required to have a youth adviser on their boards. However, there is competition for these funds, and there is concern among state lawmakers that the funds might be allocated for purposes other than opioid abatement and treatment services (as has happened with other types of settlement funds). Strategies to monitor settlement funds and ensure that they are spent as intended on youth substance use services are still needed.
Services focused on addressing substance use have gradually been moving toward integration with mental health and medical services, and this integration is often a priority for states. However, providers may have difficulty adding more components to their workflows, such as more screenings or visits. Some states are beginning to offer different payment models to support that integration work.
Ohio demonstrated success in this area with its OhioRISE (Resilience through Integrated Systems and Excellence) program, which is a specialized managed-care program for youth with complex behavioral health and multisystem needs. OhioRISE exemplifies how states can provide wraparound services, including EBPs, to keep clients in their homes and communities. OhioRISE funded traditional services but also incorporated Medicaid waivers with federal grants and a shared governance model to enhance or add services.
Panelists had many suggestions for partnerships that can encourage the use of EBPs in youth substance use services. There was general agreement that the right people, systems, and organizations need to be brought together for decisionmaking (e.g., state behavioral health agencies, Medicaid, legislators, juvenile justice, child welfare, school systems, behavioral health providers, health departments, families, people with lived experience). One essential step is the identification of influential “champions” who can take ideas from the partnership group and ensure that they are implemented.
Another way for partnerships to occur is through the thoughtful combination of funding from various sources to support EBP implementation, such as Medicaid, opioid settlement funds, and federal grants. Efforts to avoid duplicating and supplanting funds are needed so that, for example, opioid settlement funds are not used when another funding source for that service already exists. State legislatures generally need to be involved in such decisions, given their role as the accounting branch.
Panelists also described statewide governance models that use an umbrella organization to coordinate services, initiatives, and funding. The umbrella organization could communicate between the governor's office and the legislative branch to ensure that each agency has the support to implement programs. For example, Ohio established Recovery Ohio as a coordinating entity (Recovery Ohio, undated). Maryland enacted a similar model with priorities that include prevention, harm reduction, treatment, and recovery (Maryland Office of Overdose Response, undated). Other states have taken similar actions: New Jersey has been a leader in shared governance with youth behavioral health services and produced a white paper on how agencies can work together (Center for Integrated Health Solutions, 2013), and Utah has been a leader in using Medicaid for youth involved in the juvenile legal system (Strohecker, undated).
Federal and state policymakers can support the use of EBPs in youth substance use services through legislation, budget priorities, and Medicaid policy. Opportunities and challenges in implementing EBPs include increasing availability and access to care, addressing workforce challenges, influencing budgets, ensuring funding (including opioid settlement money), and integrating substance use services with mental health and medical services. Opportunities for partnerships to encourage the use of EBPs include bringing the right people, systems, and organizations together; combining funding from various sources; and creating statewide governance models to coordinate services. Given the complexity of these opportunities and challenges, partnerships were viewed as key to successful progress in achieving policy action that would support EBP use equitably and at scale.
This work was funded by the National Institute of Drug Abuse and conducted by the Quality Measurement and Improvement Program in RAND Health Care.
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