Insufficient funding is frequently identified as a barrier to maximizing the reach of evidence-based practices (EBPs). As such, increasing access to new funding is recognized as an implementation strategy. Earmarked taxes?defined as taxes for which revenue can only be spent on specific activities?are an increasingly popular financing strategy that could improve the reach of EBPs. Approximately 51 million people in the U.S. (16% of the population) currently resides in a jurisdiction that has implemented an earmarked tax for MH services. These taxes are likely to become increasingly common amidst growing public demand for enhancement of MH service systems. However, little is known about how the design and rollout of earmarked taxes might be optimized to ensure that revenue is allocated for services that are evidence-based. Little empirical guidance exists to inform the design of earmarked taxes or selection of implementation strategies to ensure that they improve the reach of EBPs. The dearth of evidence about tax implementation reflects the fact that policy is understudied in D&I research. The project's specific aims are to: 1) Identify all jurisdictions in the U.S. that have implemented earmarked taxes for mental health services and catalogue information about tax design; 2) Characterize county mental health agency leaders' experiences implementing earmarked taxes, understand the determinants of decisions about tax-funded services using the EPIS framework, and assess the acceptability and feasibility of different types of implementation strategies; and 3) Develop a conceptual policy implementation framework to improve earmarked tax design, inform the selection of implementation strategies to increase the taxes' reach of EBPs, and disseminate the framework to relevant policy audiences.
These aims will be achieved by a legal mapping study, survey of 300 county mental health agency leaders in approximately 90 counties that have implemented earmarked mental health taxes, 50 semi-structured interviews in four purposively selected counties, and integration and quantitative and qualitative data through a systematic framework development process. The project is innovative because it studies an unexplored D&I topic and is significant and will have impact because it will provide an empirical basis to select implementation strategies for earmarked taxes to enhance EBP reach. This study will set the stage for a hybrid Type 2 R01 that will apply the developed policy implementation framework to test the effects of these strategies on implementation and clinical outcomes. The project team consists of early/mid-career D&I scientists with expertise in mental health policy D&I research and legal mapping (Purtle, PI) and D&I in publicly-funded mental health services (Stadnick, Co-I) and senior investigators involved with tax implementation in California (Aarons) and Washington (Bruns and Walker).

Public Health Relevance

This project is relevant to public health because it will generate knowledge about how to enhance the ability of earmarked taxes for mental health to increase the reach of evidence-based practices that improve population mental health. More broadly, the project will generate knowledge about how public policies and funding affect decisions about the decisions of evidence-based treatments.

National Institute of Health (NIH)
National Institute of Mental Health (NIMH)
Exploratory/Developmental Grants (R21)
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Dissemination and Implementation Research in Health Study Section (DIRH)
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Pintello, Denise
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Drexel University
Public Health & Prev Medicine
Schools of Public Health
United States
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