Financing, payment, and organization and management of alcohol and other drug (AOD) treatment services are closely intertwined and together determine whether people have access to treatment, how the treatment system is designed, and the quality and cost of treatment services. Since the 1960s, changes in these arrangements have driven changes in the delivery of AOD treatment, and recent developments, including the passage of Federal parity legislation and health reform, as well as increasing use of performance contracting, promise to bring additional changes. This article outlines the current state of the AOD treatment system and highlights implications of these impending changes for access to and quality of AOD treatment services.