In the movie Annie Hall, Woody Allen’s character tells an old joke about two elderly ladies at a Catskill mountain resort: “One of ’em says, ‘Boy, the food at this place is really terrible.’ The other one says, ‘Yeah, I know—and such small portions.’ ” Well, the good news, when it comes to addiction treatment policy, is that the portions are larger—that is, reforms over the past decade have made treatment for substance use disorders accessible and affordable to more Americans than ever. The bad news is that the quality of much of that care is still terrible.
Even before the overdose crisis began claiming as many lives each year as AIDS did at its peak, the need for substance use disorder treatment in the United States was immense. More than twenty million Americans meet medical diagnostic criteria for a drug or alcohol disorder, exacting a brutal toll on their health and well-being as well as imposing substantial costs on the community, from intoxicated driving, violence, unemployment, family breakdown, and infectious-disease transmission. But because excessive substance use has until recent years been seen primarily as a sin meriting stigma and punishment, funding for addiction treatment has been in short supply. Many private employers haven’t particularly wanted to provide good insurance benefits for their employees wrestling with addiction, and taxpayers have been reluctant to fund services, with the exception of a few groups who provoke unusual sympathy and concern, like veterans and pregnant women.
However, sustained cultural and political activism, including by recovering addicts themselves, has created a new public understanding of substance use disorder and, with it, a new public policy environment. In 2008, Congress, with strong bipartisan majorities, passed the Wellstone-Domenici Mental Health Parity and Addiction Equity Act, which mandates that substance use and mental health disorder treatment benefits provided by large employers be comparable to those provided for physical health care. The same year, the Medicare Improvement for Patients and Providers Act substantially enhanced the outpatient substance use and mental health disorder treatment benefits for that program’s fifty million beneficiaries. The Affordable Care Act (ACA) advanced access even further in 2010 by mandating coverage for substance use disorder screening and treatment in health insurance exchanges and within the Medicaid expansion provisions. Along with other changes wrought by the ACA, the legislation is estimated by the Department of Health and Human Services to have improved access to care for substance use disorder treatment for more than sixty million people.
People who pushed for these massive reforms (including me) are jubilant that access to treatment has reached a historically unprecedented level. However—and it’s a big however—the long-underfunded, undervalued, rickety U.S. addiction treatment system cannot consistently provide the quality of care that policymakers, purchasers, and patients are now going to expect in exchange for a flood of new public and private money. Studies of the system have shown that most programs do not have even one medically trained person on staff who can write a prescription, conduct a physical exam, or diagnose hepatitis, HIV, or tuberculosis. Very few treatment agencies meet current standards for electronic health records, and about a quarter have no computer resources of any kind. Even billing a private insurer or Medicaid is beyond the capacity of most programs. Physical infrastructure is sometimes tatty, and clinics are frequently located in areas that make them unappealing to patients and also isolate them from other health care providers.
While many treatment agencies contain dedicated staff who offer high-quality care, one also sees the sorts of programs one expects to see when a marginalized population receives underfunded services: treatment with no basis in scientific evidence, individuals poorly trained in the professional and ethical requirements of their job, and a culture of low expectations and accountability. The prominent addiction researcher Tom McLellan used to illustrate the field’s realities with a classified ad from a Philadelphia newspaper: “Drug counselor wanted, $12,000, no experience necessary.”
When that same Tom McLellan and I were working in President Obama’s White House Office of National Drug Control Policy, we shared the view that a root cause of the often poor quality of substance use disorder treatment was its segregation from the rest of the health care system. Although it is far from perfect, the mainstream health care system has established numerous mechanisms to attract and retain well-trained staff, to apply scientific evidence in clinical practice, to protect the dignity of patients, and to improve the quality of care. Evaluations of current addiction treatment effectiveness generally show that the average patient benefits despite the challenges, and we believe that bringing addiction treatment out of the shadows and into the larger health care system would not only reduce stigma but also improve the quality of care over the long term.
The most obvious and important way to accomplish such integration was to advocate for full inclusion of substance use disorder care within the ACA. But it also involved other budgetary decisions, particularly preferring expansions of treatment funding within established federally supported health care systems such as Community Health Centers, the Veterans Health Administration, and the Indian Health Service. This was a change from the previous policy of directing federal dollars preferentially to the onetime bulwark of federal support for treatment, the $1.8 billion Substance Abuse Prevention and Treatment Block Grant to states. The block grant does significant good, particularly in those states in which this federal largesse is the only support for services. However, it has never had any mechanism to promote quality of care (like pay for performance), nor have the states shown any enthusiasm about such standards being imposed. Further, the set-aside funding led to a set-aside treatment system with little connection to the services and quality improvement mechanisms of the mainstream health care system. In addition, block grant funding continues to decline in real terms each year. For providers who adapt to the realities of the new policy world, the surge of new public and private funding will more than compensate for the loss of the old funding stream: Medicaid spending alone in 2020 is projected to be more than ten times that of the block grant.
With the new funding and new legitimacy will come new expectations. Substance use disorder treatment programs, like the rest of medicine, will have to consistently employ qualified staff, make use of evidence-based methods, maintain state-of-the-art health care records, and be a part of modern health care networks. The transition will be bumpy, but it is also necessary. Advocates have already won the challenging cultural battle to convince most of the country that addiction is a legitimate health problem. Now we must ensure that those experiencing it receive quality health care.