“Targeting within universalism”—health reform and substance abuse policy

I wrote this post returning from England, where I attended the annual meeting of the International Society for the Study of Drug Policy. ISSDP is a key organization of researchers and practitioners concerned with alcohol and illicit drugs. Experts from all over the world met in Canterbury to discuss police strategies regarding street cocaine markets, what to do about the world heroin market, HIV prevention among injection drug users.

You might ask what all this has to do with health reform: A lot, actually. The Affordable Care Act is the most important law ever passed to expand access to substance abuse treatment in this country.

My session included a nice discussion of these matters with Stanford University’s Keith Humphreys. Keith interviewed many of the key players at the interface of drug policy and health reform. He was a key player himself, serving as a senior advisor in the early Obama years in the drug czar’s office.

The fine print of ACA includes significant provisions to improve substance abuse treatment. Because these services are considered an essential health benefit, public and private insurers have to cover these services. Parity regulations require insurers to offer these services under the same terms as other health services. Insurers will no longer be able to charge separate (and higher) deductibles for substance use services than is charged for other services. Insurers will no longer be able to impose separate (and lower) annual or lifetime limits on such care.

Important preventive services are also included, such as screening and brief interventions for alcohol misuse in emergency care. Perhaps five million Americans with alcohol or illicit drug problems will gain coverage under ACA who would otherwise go uninsured.

Given the intense stigma surrounding substance use, ACA provides an excellent example of “targeting within universalism,” as a strategy to implement humane policy. Among many aspects of Keith’s account, it’s striking to see how mental health and substance abuse treatment advocates learned from the defeats of the 1993/94 Clinton effort. A broad coalition, with significant bipartisan elements, methodically organized, influenced key legislators on both sides of the aisle, and was ready to act by 2006 when Nancy Pelosi assumed the speakership and that noted liberal–George W. Bush—supported parity legislation.

These advocates got far more than they expected to get when health reform was crafted in the House and Senate bills. Once the debate was reframed from an exclusive focus on specific services to an unpopular population to the broader question of social insurance that guarantees every American access to affordable health coverage, the politics became much more favorable in ensuring proper inclusion of substance abuse services.

It’s a sad commentary on American politics that many treatment advocates decided to maintain a low profile as the Affordable Care Act was passed. When angry public debate included many false claims about death panels and services to undocumented immigrants, trumpeting health reform’s value for substance users might have proved politically damaging. I understand the strategic calculus in getting an important bill passed.  Ironically, many Americans whose lives have been touched by these matters do not realize that these provisions are even there.

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