Your mileage may vary, but this seems to me like a very sensible conversation, at least on Reihan’s side. A good interviewer is hard to find.
Given how often some people demand “health-oriented drug policy” from the Obama Administration it is more than a little peculiar how one of the biggest reforms in history didn’t attract more attention and draw more praise in the blogosphere. With the Administration’s declaration that treatment of mental health and substance use disorders are essential health care benefits, to be provided not only in the state health insurance exchanges but in all new individual and small-market health insurance plans, over 60 million Americans just got better insurance coverage for these disorders. The graphic below is from HHS:
That isn’t the end of the good news. The more than 100 million Americans who receive coverage under large-group plans are also getting better coverage due to the Mental Health Parity and Addiction Equity Act. Passed in the waning days of the G.W. Bush Administration with the regulations being written by the Obama Administration, the law mandates that any offered benefits for addiction and mental health must be comparable to those offered for other conditions.
But wait there’s more: Medicare, which enrolls almost 50 million people, has long had inferior coverage for addiction and mental health outpatient care, reimbursing only 50% of costs versus 80% of those for other forms of medical care. Thanks to a provision in the 2008 Medicare Improvements for Patients and Providers Act (again, give it up for the 110th Congress and President Bush), this disparity in reimbursement is being phased out and will be entirely eliminated by January 1 of next year.
When you consider that addictions almost always evidence themselves in adolescence or early adulthood, it becomes clear that the ACA provision allowing parents to keep children on their insurance until age 26 adds yet another layer of protection for the population.
Some people of course have coverage from more than one of the above sources, but even granting that overlap, over 200 million Americans have gotten improved insurance coverage for treatment of drug and alcohol problems (and mental health disorders as well). This includes many people who were starting with nothing, as well as a large population that had a benefit of inferior quality.
This is the biggest expansion to access to care for addiction in at least 40 years and probably in American history. In financial terms, it is certainly the biggest commitment of public and private resources to the health care of people with substance use disorders in U.S. History. Congratulations are in order to countless grassroots advocates, civil servants, political appointees, members of Congress and two U.S. President for transforming the face of health care for addiction.
Our friends at Washington Monthly have provided a vivid example of a piquant feature of drug legalization debates.
As a group, the editors and writers at Washington Monthly have been broadly supportive of the proposition that we should regulate marijuana like alcohol. Yet the current issue carries Tim Heffernan’s expose on the monopolistic, addiction-generating, profit-grubbing ways of…you guessed it, the alcohol industry.
I am not picking on our WashMo friends as some sort of bizarre exception to the rule, they are very much in the left-wing mainstream: Strongly convinced that marijuana should be regulated like alcohol, while simultaneously being completely distrustful of the very industry they are holding up as a model (this is even moreso the case when the comparision is made to the legal tobacco industry).
Meanwhile on the political right, a parallel role reversal occurs. Most conservatives want to punch those dirty hippees who are trying to push back government control and make way for a private sector business because, damn it, that’s, that’s…wait a minute, that’s what WE always say is a good idea! Those damn hippees stole our playbook!
What is going on? Why do liberals who are normally skeptical of corporate power and aware of the limits of government regulation become wide-eyed innocents when singing the virtues of a legal marijuana industry? Why do government-hating pro-business conservatives suddenly want the government to stamp out all the private sector marijuana entrepreneurs?
Way too many aspects of U.S. politics are explained as being a “legacy of the 1960s and 1970s”. But…this is a legacy of the 1960s and 1970s. The cultural coding of marijuana as a thing that liberals like and conservatives hate is so strong that each group tends to ignore all its other beliefs on this issue and adopt the other’s traditional stance.
I am not a baby boomer, so the odds are I will never get this at a gut level because I wasn’t “there”. But it still fascinates me as a sociopolitical phenomenon.
It is very difficult for elected officials to talk seriously about drug policy reform (It is easy for them to talk about it non-seriously, but that’s a separate matter). The issues require nuanced dialogue, but the debate is dominated by polarized shouting matches. Reform minded politicians are typically reduced to un-sound-bite-worthy statements such as “I’d like to reduce the number of people in prisons but I am against the legalization of drugs so don’t accuse me of that” or “I think we need to be tougher on violent drug markets but I mean violent dealers not drug using teenagers so please don’t accuse me of being a heartless drug warrior”. It’s a lot of work and political risk to fight for a cause that most voters aren’t too thrilled to hear about in the first place.
I recently had the honor of being asked to join an advisory council to the New Jersey Governor’s Council on Alcoholism and Drug Abuse. The main reason I agreed is that Chris Christie is one of the few governors in the U.S. who is elevating drug policy reform discussion in a way that both does justice to the complexity of the issues and acknowledges the need for change. Here are two 60 second snippets; the reaction to the second is particularly noteworthy.
Given that I am in London and sitting in the very chair you see pictured here, it is only natural that I make this weekend’s film recommendation the movie in which it appears: Matthew Vaughn’s stylish and brutal “Layer Cake”. That’s obviously not me pictured, but the magnificent Sir Michael Gambon. He plays wily drug kingpin Eddie Temple in one of the great British gangster films (which is saying something, they have been making outstanding movies about guns and geezers over here for three quarters of a century).
The film centers on cocaine middleman “Mr. X”, played convincingly by a pre-James Bond Daniel Craig. One of the many things the film gets right about the illegal drug trade is that it includes people like Mr. X who think they can make big money while remaining untouched by the damage that drugs do downstream and the violence and immorality of the kingpins who call the shots upstream. Mr. X tells himself he is just a businessman whose commodity happens to be illegal, and that he will simply leave the drug trade behind him when he is financially secure. But when drug honcho Jimmy Price (Kenneth Cranham) gives him an unusual assignment, his assumptions are shattered and he quickly gets in way, way over his head. Meanwhile, he develops a serious case of the hots for a low-level gangster wannabe’s girlfriend (played by Siena Miller…rumor has it that she and Craig prepared for their scenes together Lee Strasberg-style).
The supporting cast is uniformly strong, especially Colm Meaney as a long-time gangster. There are some over-the-top camera shots by Vaughn which some people found self-conscious and annoying, but they work well given the kinetic story line. And Gambon’s soliloquy on “the facts of life” is as quotable and as well-delivered as anyone could ask.
p.s. This film is rated R with an exclamation point, so by all means don’t bring the kids.
p.p.s. Vaughn shot three different endings for this movie, all of which I’ve watched and he definitely picked the right one.
Drug policy research is at best a modestly sized field. Nonetheless, its findings have significant potential to help societies develop more effective public policies regarding marijuana, heroin, cocaine, nicotine and other psychoactive drugs. I am therefore very glad to announce that an extension of the international drug policy research integration conducted for the book Drug Policy and the Public Good appears today in The Lancet. A generation ago, a reviewer of the world’s drug policy research findings would have been pressed to fill even one article in such a prestigious scientific outlet; the field has clearly matured since.
The three review papers have different foci:
*Louisa Degenhardt and Wayne Hall integrate the international evidence on the contribution of illicit drug use and addiction to the global burden of disease.
*Peter Reuter and Robin Room make their case that the international drug conventions succeed neither in providing medications (e.g., opiates) where they are needed nor in preventing the availability of widely abused drugs
*John Strang, Tom Babor, Benedikt Fischer, David Foxcroft, Jonathan Caulkins and I discuss “what works” in drug policy, reviewing the evidence on source country control, interdiction, policing, prevention and health and social services for drug addicted individuals.
Lancet has made the articles available with a free registration here.
A shorter take on some of the key conclusions in the third paper is also available for free in an op-ed by Jon Caulkins and me in The Guardian (UK) today.
I have spent too much time in public policy circles to be starry-eyed about the likelihood that scientific evidence will be always be heeded in a policy area that is often dominated by demagogues of various stripes. Yet I also see many positive signs in Europe and the U.S. of openness to information in quarters that had previously been a mix of loud voices and closed ears. Scientists cannot and should not control drug policy (that would be grossly undemocratic), but they certainly can contribute systematic and reliable findings to the policy debate and insist that serious research be given more weight than wishes, hunches and anecdotes. The reviews of the drug policy research knowledge base in The Lancet today are offered to policymakers and the public in that spirit.
Please consider this an open thread to debate and discuss anything in The Lancet papers if you are so led.
UPDATE: Here is a short interview with Dr. John Strang about the evidence for effective drug policy interventions
Alejandro Hope, until recently in charge of organized-crime analysis at CISEN (the Mexican intelligence service) shreds the latest nonsense numbers from the UN Office on Drugs and Crime.
Part of the problem with drug policymaking at every level is its almost complete detachment from reality. In particular, statistics about drug volumes and revenues are more or less invented at random, then passed around like bad pennies.
I have this flagged under “Lying in Politics,” but “lying” isn’t really the mot juste. This is more what Harry Frankfort calls “bullsh*tting”: the statements are false, but not really intended to deceive. Stating them, and citing them, are ritual gestures: socially meaningful, but essentially content-free. (And debunking them is one of the central themes Jon Caulkins, Angela Hawken, and I pursue in Drugs and Drug Policy, whose subtitle should really be, not “what everyone needs to know,” but “what everyone needs to stop believing.”
Translation below the fold.
Footnote More from Alejandro at his new blog (mentioned earlier by Keith). It’s called “Plata o plomo” (“Silver or lead”), the proverbial choice offered to law enforcement officials by Latin American drug traffickers: take our money or face our bullets.
Starting tomorrow, Stanford’s Center for International Security and Cooperation will host a two-day conference on violence, drugs and governance in Mexico. In preparing for the event (at which Mark Kleiman will also be in attendance), I decided to try to estimate the current revenue streams of the Mexican organized crime organizations (MOCOs). I leaned heavily on RAND research and on the analyses of colleagues in Mexico to generate my estimates, so credit for whatever is correct in these charts goes to them whereas any errors are solely on my own head.
The most difficult thing about getting current revenue streams correct is estimating how much the MOCOs are making from non-drug-related activities (e.g., smuggling immigrants across the border, pirating videos, kidnapping, extortion). Everyone I read or talked to agrees that this line of MOCO revenue is growing, but estimates of how large it is were divergent. The first chart here uses the low-end estimate among experts of 15% non-drug revenue. If this estimate is correct, the MOCOs are still largely one dimensional drug trafficking organizations, with principal profit coming for cocaine. Note that were we mapping drug markets more generally, cocaine would be a much larger share of the pie but because much of that money is made by Colombian gangs, the share for the MOCOs is smaller.
The drug-related pie slices are all based on the national U.S. market revenue, with one exception. Because California had a ballot proposition to legalize marijuana, I have broken out the California marijuana revenue stream separately. It’s about a seventh of the total. Continue Reading…
Over the past four years, the number of people self-reporting as methamphetamine users on the big household survey is down by half, and meth initiation rates – a leading indicator, and therefore the one to watch – by 60%. The number of people self-reporting cocaine use is down by a third. Middle-school rates of drinking and smoking are also down, though less dramatically. Initiation to non-medical pain relievers remains high, but off its peak in the early 2000s, reached after a decade that saw initiation rise tenfold.
Oh, yes, and cannnabis use is up some (almost 20% from the 2007 trough, from ), especially among young adults (18-25). Cannabis use among those under 18 is flat. Mean age at first use is up from 17 to 18.4: that’s the direction you want to see it going.
So the on-one-foot summary of the results is “Nothing exciting, but basically good news.”
But if you were really, really, really stupid – or had a job that required you to pretend to be that way – you might just treat all use of illicit drugs as alike and simply count the number of users. In that case, the modest rise in cannabis use would swamp all the other results, because cannabis is by far the mostly widely used illicit drug, and a report mostly full of pretty good news would come out as “National Survey Shows a Rise in Illicit Drug Use,” complete with silly viewing-with-alarm quotes from officials.
(No, dammit, we are not “at a crossroads”! Next year is mostly going to look like this year.)
Even after 30 years in the business, it’s hard to get used to how plain damned dumb the official (and journalistic) discourse on this topic is. The household survey (aptly named NS-DUH, where DUH is pronouned “duhhhhhhhhh”) doesn’t get at what’s really interesting: the number of problem users, and especially criminally-active problem users. But it does contain some useful information. Too bad the people running the show mostly ignore that information and concentrate on fluff.
The latest Foreign Affairs has my essay offering some ideas about drug policy, at right angles to the drug warrior/legalizer debate. It’s behind a paywall, but I can supply a .pdf on request.