The competence of the post office
    and the compassion of the IRS,
brought to you
    by your friendly local health insurance company

About twenty percent of hospital admissions involve people with drinking problems, which is somewhat more than twice the proportion of problem drinkers in the adult population. For emergency rooms and trauma centers, the proportion is almost certainly higher; some say as much as 50%.

Brief intervention by a physician — roughly, saying “You’re drinking too much and need to cut it out,” followed by a treatment referral if the patient wants one — has been shown to be modestly effective, and, because it’s so cheap, wildly cost-effective, and in fact cost-saving on balance. A brief interview protocol turns out to be quite successful at identifying problem drinkers. Yet the health-care machinery notoriously displays an almost total lack of interest in patients’ drinking behavior.

Rachel Zimmerman, writing in yesterday’s Wall Street Journal seems to have figured out part of the reason: half a century ago, the health insurance industry lobbied a law through in 38 states allowing them to refuse payment for medical care required as a result of intoxication by alcohol or other drugs. So a hospital that runs the test and records it in the patient’s chart is setting itself and the patient up for financial disaster. Result: they don’t look.

A spokesgoon for the Health Insurance Association of America is shocked and appalled that the hospitals aren’t volunteering to let the insurers screw them out of their reimbursements. And naturally he asserts that changing the rules would drive up insurance costs, which seems grossly implausible given that the hospitals mostly aren’t testing now and that the consequence of not testing is more health-care costs in the future. I think HIAA is now so used to opposing things that are good for the country’s health that they now assume that anything that’s good for health is bad for them.

[Note to Ph.D. candidates: Great research opportunity here. Try a cross-section analysis of the frequency of tox screening in states with and without such laws, and an interrupted time series on the states that just changed over.]

[Note to libertarians: Go ahead. Tell me how the market is going to solve this one, in the face of the obvious adverse-selection problem: being the one insurance company that offers coverage for drinking-induced accidents is going to be a marketing advantage only in selling to drunks, who are lousy health care risks.]

[Note to Democrats: So what are you waiting for? Here’s a little-guy-vs.-the-big-companies issue that’s also obviously good public policy. Go!]


Glen Whitman takes up my challenge to libertarians. His answer — essentially, the creation of a special underwriting category for alcohol and drug abusers, who would pay higher insurance rates than the more abstemious — makes sense, as most libertarian solutions do, if you abstract from a few facts:

— Much health insurance is bought by employers for employees, rather than individually.

— Being an alcohol or drug abuser isn’t (1) a simple yes-or-no; (2) a stable condition over time; or (3) an easily observable condition; the usual diagnostic approach is asking the person involved, which isn’t going to work very well if the consequence of saying “yes” is having to pay higher insurance rates.

— Someone who isn’t clinically diagnosable as an alcohol abuser can still wrap his car around a tree.

— Having all the drunks and drug abusers uninsured — the likely consequence of charging them the expected-value cost of their health insurance — means that the rest of us wind up paying for their care through the unpaid care accounts kept by hospitals and passed through to insurers, unless we’re willing to have them die in the streets. The whole logic of treating medical care as an ordinary commodity falls apart once you say, “No, we’re not prepared to have people who can’t pay for care die for want of care.”


A reader notes the use of “Quite frankly” in its modern idiomatic meaning, which is roughly “The following sentence is so astonishingly mendacious that I’m going to have trouble saying it without laughing out loud. You are requested not to notice.”

February 26, 2003

Why Emergency Rooms Rarely Test

Trauma Patients for Alcohol, Drugs



Alcohol-related accidents and mishaps left Alan Levine with two amputated feet, a broken back, a ruptured spleen and only four remaining teeth.

Yet in 10 visits to emergency rooms in California, Nevada, Oregon and Washington, he says he was never tested for alcohol in his blood, nor was he ever urged to get counseling. “None of the so-called professionals mentioned treatment or counseling or gave any indication there was something wrong,” says Mr. Levine, 57 years old, who stopped drinking several years ago and now volunteers as a substance-abuse counselor in Portland, Ore.

In fact, most of the nation’s emergency rooms and trauma centers don’t routinely run blood-alcohol tests or “tox screens” on patients thought to be intoxicated. Why? At trauma centers, which treat the most seriously injured patients, the first priority is generally to save lives and provide immediate care. But doctors say another big reason the tests aren’t performed is the obscure, decades-old laws adopted in 38 states and the District of Columbia that give insurers the option to deny medical reimbursements to patients under the influence of alcohol or narcotics.

Aware that health-insurance policies can contain this exclusion, hospital staff seldom run the tests or urge counseling, for fear the results will appear in claims records and reimbursements will be denied. “Doctors don’t test because they’re afraid they won’t get paid,” says Larry Gentilello, the 49-year-old chief of trauma and surgical critical care at Boston’s Beth Israel Deaconess Hospital.

Dr. Gentilello has been waging a grinding, three-year fight with insurers, regulators and state lawmakers to repeal the laws and make drug and alcohol tests and counseling a routine part of trauma care. He has the support of groups including Mothers Against Drunk Driving, the National Highway Traffic Safety Administration, the National Association of Insurance Commissioners and the American Society of Addiction Medicine, but progress has been slow. Maryland, North Carolina and Vermont have repealed their laws, but repeal efforts have failed in legislatures in New York, Washington and Arizona.

A three-time college dropout, Dr. Gentilello grew up in New York’s Washington Heights, drove a Checker cab and worked at a White Hen Pantry convenience store before applying to medical school. During his surgery residency at the University of Texas Health Science Center in Houston, he began to wonder why trauma care for substance abusers wasn’t automatically linked to counseling.

In a three-year, federally funded study published in the Annals of Surgery in 1999, Dr. Gentilello looked at more than 700 trauma patients admitted to Seattle’s Harborview Medical Center for alcohol-related injuries. The patient group that received 30 minutes of counseling at the hospital experienced a 47% reduction in serious injuries requiring trauma-center admission in the following three years, plus a 48% reduction in less-serious injuries requiring ER care.

With alcohol and drug-related injuries accounting for as much as half of all trauma-center visits, such reductions on a national scale could save as much as several billion dollars a year in health-care spending, Dr. Gentilello figures. But eager to cut costs, insurers are denying alcohol and drug-related claims more often, he believes.

Dr. Gentilello says insurers’ denial of coverage to substance abusers is short-sighted and discriminatory. “Do we not treat venereal disease if the person did not wear a condom? Do we not treat emphysema in a patient who will not stop smoking?” he asks.

Jeffrey Hammond, chief of trauma and surgical critical care at Robert Wood Johnson University Hospital, New Brunswick, N.J., says doctors’ awareness of denied reimbursements has led to a steady decline in testing and counseling during the past five years. Ideally, most adults admitted to trauma centers would be tested and referred to counseling when appropriate, he says. But without the assurance of payment, many hospitals and doctors can’t afford to jeopardize profits by providing such preventive care. “No margin, no mission,” Dr. Hammond says.

Philip Barie, director of the surgical intensive-care unit at New York-Presbyterian Hospital in Manhattan, says he routinely avoids testing patients’ blood alcohol because he doesn’t want to risk having their insurance claims denied. Once a blood-alcohol test is completed, “it’s in the record and they have grounds to deny the claim,” Dr. Barie says. “Hospitals are not in business to lose money, and doctors depend on the billings.”

Insurers say they can’t afford to cover everything, and the cost of claims would go up, not down, if they had to cover all the injuries of people under the influence of alcohol and drugs. But beyond economics, they say, there’s an ethical concern: Medical needs, not insurance coverage, should drive health-care decisions.

“Quite frankly, I’m a little disheartened that physicians would base their treatment decisions on whether or not they might be reimbursed by an insurance policy,” says Larry Akey, spokesman for the Health Insurers Association of America, a 300-member trade group. The HIAA has argued that doctors who won’t order tests and counseling for alcoholics and drug abusers because of financial concerns are guilty of a “shocking abdication of responsibility.” Trauma doctors don’t need permission to test for drugs or alcohol while treating their patients.

The state insurance laws at issue are based on the Uniform Individual Accident and Sickness Policy Provision Law, or UPPL, a model law drafted by state insurance commissioners in 1947. The HIAA’s Mr. Akey says a number of the group’s members have such provisions in their policies but wouldn’t identify which companies. Aetna Inc. and Cigna Corp., two of the nation’s largest health insurers, say they don’t have such provisions.

But Dr. Gentilello says Cigna recently denied a trauma-care claim at Boston’s Beth Israel because the patient was intoxicated. He says the hospital fought the denial, and eventually Cigna paid. A Cigna spokeswoman says the company can’t comment without the patient’s name; Dr. Gentilello says he can’t name the patient due to confidentiality rules.

Deana Watterson, a 44-year-old waitress in Mouton Cove, La., suffered a ruptured duodenum and other internal injuries in a 1997 car accident. Because there was alcohol in her blood, she says, her insurer didn’t cover the nearly $200,000 cost of her treatment at Our Lady of Lourdes hospital, in Lafayette. She filed for personal bankruptcy; the hospital wrote off the costs. The lesson? “Given the option, I don’t order blood-alcohol tests,” says Christopher Lee, the surgeon who treated her. “And I ask the ER docs not to order them.”

Write to Rachel Zimmerman at

Updated February 26, 2003,,SB1046213237955719943-search,00.html?collection=wsjie%2F30day&vql_string=alcohol%3Cin%3E%28article%2Dbody%29

More on cannabis:
    autonomy, medical use, and the supremacy clause

Matthew Yglesias doubts that keeping someone from damaging himself through coercive means counts as a benefit. Well, turn it around: does inducing/allowing someone to damage himself by setting up a dumb choice for him to make count as a harm? If what Matthew proposes is a counting rule, I don’t see its justification. The principle of autonomy leads me to think that restricting people’s choice ought to be counted as a cost, but not that its benefits in the form of avoided self-damage should be ignored on principle.

Imagine that you were running an oceanside resort, with a beautiful walk along the cliffs that was dangerous in high winds. How many people would have to fall to their deaths, despite your sign saying “Don’t walk here when it’s windy,” before you decided that the path had better be closed?

Whether we’re comparing the grow-your-own policy against full legalization or current prohibition against grow-your own, can it really be right to ignore as a matter of principle the impact of looser controls on the rate of drug abuse and dependency? And as a practical matter, how serious a restriction would it be on autonomy to say that people who wanted to use cannabis had to either grow their own or find a generous friend with a green thumb?

Matthew also proposes that banning cannabis for everyone makes it more available to kids than allowing it for adults and forbidding it to kids only, which is his preferred alternative. I can’t see how that works. Making it legal for adults doesn’t interfere, in any obvious way, with clandestine growing for the juvenile market, and cannabis is so much more compact than alcohol (a pound of beer is a 16-ounce can, while a pound of pot is a thousand doses) that the leakage around a cannabis age barrier would be even more copious than the leakage around the alcohol age barrier. Moreover, age limitations make the use of the substance involved a badge of adulthood, and encourage kids to learn the mechanics of lawbreaking. [If I had my way, the age restriction on alcohol would go; it does some good in preventing drunk driving, but the notion that having a false ID is a normal thing for a college freshman to do makes me extremely uncomfortable.]

Matthew’s original post was a reflection on a New York Times editorial complaining about the conviction of a California medical-marijuana grower in a Federal court in which the judge barred any testimony that would have told the jury why he was growing the pot, or that he was doing so as an agent of the City of Oakland. The jurors, having convicted him of a crime carrying a five-year mandatory sentence, were extremely upset when they discovered the context of which the trial process had carefully kept them ignorant. Ampersand agrees with the Times, but wants to know what I think about it.

First reaction: yawn. Medical marijuana is not an important issue medically (Dutch doctors, whose patients have easy access to the drug, don’t use it much) and not an important issue for drug policy. It was clever of the drug-legalization movement to make medical marijuana the battleground, and foolish of the drug warriors to accept battle on ground so favorable to their foes. [I’m not saying that any individual drug warrior or drug-war group is foolish; any one of them who said “This is the wrong battle to fight” would have been excommunicated. That’s the problem with running a movement based on thought police.] But as a practical matter the whole business is barely worth talking about. That hasn’t kept me from doing so, of course.

Substantively, my view is that the only way to make marijuana available as a medicine (other than legalizing it outright, which isn’t going to happen anytime soon) is to put it through the FDA process. If a tenth of the money and energy that has gone into litigation and referenda had gone instead into medical research, cannabis would now be a Schedule II drug. But the one point the warriors and the legalizers agree on is that this is a topic to be argued about, not one to be studied scientifically. (That agreement is at a pragmatic, rather than a rhetorical level. The drug warriors insist that cannabis cannot be approved as a medicine without more research, and then do their best to make research impossible; the medical pot crowd — with the exception of Rick Doblin — pretends that adequate research has already been done and therefore makes no effort to get any going.)

Legally, Judge Breyer did precisely the right thing. The Supreme Court ruled (overturning one of Breyer’s decisions) that, as a matter of law, cannabis has no medical use, and that therefore the issue of its medical value could not be raised in court. Under the Supremacy Clause, a California initiative does not trump a federal prohibition. Growing cannabis is against federal law, and growing it under contract to the City of Oakland is against federal law to precisely the same extent as growing it to supply an army of pushers lurking outside elementary schools.

Moreover, even California Proposition 215 doesn’t permit someone to grow a thousand marijuana plants to be distributed to patients though “buyers’ clubs.” Prop. 215 provides merely that a patient in need of cannabis, or that patient’s “primary caregiver,” may grow or possess cannabis. It’s clear from the text that a “primary caregiver” is understood to be a close relative or friend who takes responsibility for an individual patient. “For the purposes of this section, ”primary caregiver” means the individual designated by the person exempted under this section who has consistently assumed responsibility for the housing, health, or safety of that person.” The idea that a buyer’s club, which of course is not an “individual” at all amd which does not assume general responsibility for its clients, can be the “primary caregiver” for hundreds of people at a time is utterly fantastic.

Had the jury known all the facts, it would have nullified the law by acquitting a person clearly guilty under its terms. I’m not going to get into the argument about whether that’s a good idea, but under current law the defense isn’t allowed to argue that the jury should do so, or present evidence relevant to the nullification but not to legal culpability. The five-year mandatory for large-scale pot growing is unconscionable, and the Justice Department decision to frame the charge in a way that triggered the mandatory is something for everyone who contributed to it to be ashamed of. But the legality of what Ed Rosenthal was convicted of doing isn’t really an open question; is there some part of the phrase “supreme law of the land” that his lawyers would like explained more carefully? In any case, ragging on Judge Breyer is pointless: he was just doing his job.

Cannabis policy and the “grow your own” option

Matthew Yglesias makes a true statement but draws what I think are two false inferences from it:

It’s true that “the new public service ads the government has out to denounce the weed all make reference to things (the risk of jail time, the associated violence, etc.) that are caused by criminalization rather than marijuana use itself.” But that doesn’t prove that “making [marijuana] illegal is helping no one and harming many” and that, therefore, “the campaign against marijuana makes no sense at all in any of its manifestations.”

Most of the arguments made in favor of keeping cannabis illegal are no better than the ones Matthew cites. I take on one of them here. And it’s true that much of the damage done by cannabis results from its illegality.

But it’s not true that it’s harmless, or that the current laws don’t reduce its use.

Cannabis is substantially more habit-forming than most non-drug-warriors believe; of all those people who have smoked it at least five times, roughly a tenth go on to some extended period of heavy daily use. As an academic acquaintance (whose libertarianism makes him a supporter of legalization despite his personal experience) put it, “I’m just like all those politicians. I only used marijuana a single time, and I deeply, deeply regret it. The single time was from the spring of 1963 to the fall of 1969.”

Being a pothead isn’t nearly as bad for you, or for the people around you, as being a drunk. It doesn’t cause violence, it doesn’t rot your liver, and, for most people, the period of continual intoxication passes after several months and doesn’t return. But some people — everyone my age knows a few — get caught in very-long-term patterns of dependency, and even the shorter period is nothing to write home about, putting aside the risk of being busted. If it happens to coincide with, say, the tenth grade — and cannabis initiation happens much earlier now than it did twenty years ago — some schoolwork, and some emotional growing-up, are likely to be missed, and not all of what’s missed is going to be made up later.

The claim that the laws don’t reduce use — which Matthew doesn’t make explicitly, but which would have to be true for it to be the case that prohibition benefits no one — is thoroughly implausible, though the extent of the increase in use that would result from legalization would depend on the details (tax level, distribution system, marketing restrictions, age restrictions, potency and quantity restrictions) of the legal regime that replaced prohibition. Even as an illegal drug, cannabis is cheap on a per-hour-intoxicated basis (probably something under a dollar for a user who hasn’t built up a tolerance), which would limit the impact of a price decrease on consumption levels. Still, the stuff that now sells for $150-$300 an ounce would presumably be more popular if it cost a tenth of that or less, which would be the (pretax) legal price. There’s no reason to think that cannabis demand is completely price-inelastic. Moreover, legality would make the stuff easier to come by and reduce the formal and informal social consequences of smoking. Even the poorly-enforced regime of alcohol prohibition reduced the amount of alcohol consumed by something between half and two-thirds.

If marijuana proved to be a substitute for, rather than a complement to, alcohol (the studies conflict) then making it legal would probably reduce crime and accidents. Legalizing it would also reduce the population behind bars by about 60,000, or 3%. Legal cannabis would eliminate a $10 billion per year illicit market, which even if its contribution to terrorism is negligible is still a noticeable social headache, and get several million people whose only current criminal activity is using pot back on the right side of the law: not a negligible benefit, in my estimation.

But if that meant that the current population of 2 to 3 million wake-and-bake potheads tripled, I’m not sure that would be a good trade. And legalization on anything like the alcohol model could easily lead to such an increase. Just think what the people who have convinced so many American kids to smoke tobacco cigarettes and drink beer could do if given free rein to market what in some ways is a much more attractive product. A legal cannabis industry, like most industries, would be heavily dependent on its steady, high-volume customers: the frequent flyers. (In the case of alcohol, 50% of the total industry volume goes to people who average four drinks a day, year-round, or more.) That means that a legal pot industry would be in the business of creating and sustaining potheads. The free market is a wonderful thing, but you don’t want it working against you in a situation like that.

If I got to make the laws, I think I’d make selling cannabis, or trading it for anything of value, a crime, but legalize growing your own, using it, or giving it away. That wouldn’t eliminate sales activity entirely, but it would eliminate mass-marketing. Yes, I can think of a bunch of objections to a “Grow your own” policy, but it may still be the least bad of our options.

[More here.

Turnover at DEA

Asa Hutchinson will be leaving his post as Administrator of the Drug Enforcement Administration to take a third-level job with the new Homeland Defense Agency. Hard to figure what this means.

I met Hutchinson last year. Good-looking, smooth, articulate, friendly, inquisitive, and ambitious. An excellent explainer — potentially in the Clinton class — though without Clinton’s impulse to actually understand what he was taking about. His knowledge of drug policy was strictly at the campaign-speech level, but I watched him utterly captivate a group of University of California students who were mostly about as far as you could get from him on the issues. No resemblance at all to the image the phrase “graduate of Bob Jones University” calls to mind in a bicoastal elitist like me. Watch that space: he could be President someday, especially since his brother’s defeat means that he has a clean shot at a Senate seat six years from now.

The DEA job was Hutchinson’s reward for his work as one of the “managers” of the Clinton impeachment; he gave up a safe House seat to take it. As DEA Administrator, he’s done nothing in particular, but that’s about par for the course. He’s gotten some ink, though mostly on issues such as medical marijuana and assisted suicide, which may not be political winners. Why the move?

One possibility is that Hutchinson has decided that the drug war in general isn’t a career-builder, or that a year and change fighting it has punched that ticket and it’s time to get his terrorism ticket punched.

Then, too, there’s a buzz that Mitch Daniels is about to take the budget axe to the drug-fighting effort. Maybe Hutchinson decided that presiding over a cutback wouldn’t be any fun.

The other possibility is that Hutchinson is being moved aside for someone who really wants the job. Rudi Giuiliani, maybe? If not — if Bush puts someone low-profile at DEA — that will be a strong signal that he’s de-emphasizing the drug issue. (The only news story that even bothered to speculate mentioned the possibility of promoting the career No. 2 guy, which would be a first; DEA has always gotten its bosses from outside.) The Walters appointment already hinted at such a de-emphasis.

While I naturally have lots of activist ideas about drug policy — that’s what I do for a living, after all — I agree with my friend Peter Reuter (who spoke gratefully about the 2000 Presidential race as the first “drug-free campaign” since 1976) that in general the issue could benefit from a good leaving-alone by elected officials and candidates. Since they’re not allowed to say anything true, it’s probably better for them to say nothing.