Don’t ask, don’t look: concerning health-care screening for alcohol abuse

Scrolling through old posts to find candidates for recycling to The Atlantic, I ran across this one about why hospitals fail to screen trauma victims for alcohol abuse. It seems that laws in 38 state allow insurers to refuse coverage to patients under the influence. The resulting incentive structure leads to terrible health (and cost) outcomes.

Query: Does anyone know whether the ACA changes this?

Author: Mark Kleiman

Professor of Public Policy at the NYU Marron Institute for Urban Management and editor of the Journal of Drug Policy Analysis. Teaches about the methods of policy analysis about drug abuse control and crime control policy, working out the implications of two principles: that swift and certain sanctions don't have to be severe to be effective, and that well-designed threats usually don't have to be carried out. Books: Drugs and Drug Policy: What Everyone Needs to Know (with Jonathan Caulkins and Angela Hawken) When Brute Force Fails: How to Have Less Crime and Less Punishment (Princeton, 2009; named one of the "books of the year" by The Economist Against Excess: Drug Policy for Results (Basic, 1993) Marijuana: Costs of Abuse, Costs of Control (Greenwood, 1989) UCLA Homepage Curriculum Vitae Contact:

11 thoughts on “Don’t ask, don’t look: concerning health-care screening for alcohol abuse”

  1. Not sure, but a really valid point. I have read several cases where insurers contest the payment of benefits because the individual was under the influence of alcohol. It hadn't occurred to me that hospitals intentionally fail to develop evidence of alcohol consumption in order to avoid this outcome. Usually, the evidence is adduced by police, if they are called to the scene and can get it.

  2. I litigated a case like that — the insurer's TPA wanted a patient out of acute-care and into my client's specialty hospital, to save $$, but knew from chart review that the patient showed as legally intoxicated on a blood-alcohol test. The TPA omitted to mention that little fact when getting the patient admitted, despite being asked about any exclusions to coverage.

    After the district court denied summary judgment, and pointedly noted that punitive damages were still on the table, the TPA settled (quite handsomely) a few days before trial.

    As a colleague of mine asked at the time, "if insurance doesn't cover what happens to you when you're drunk, what damn good is it?"

  3. Let's see, TPA is a TLA (Three Letter Acronym) for something or other. I wonder what that could be?

  4. Not an expert, just regurgitating what I've read: I think under the ACA insurers can't refuse anybody coverage, nor can they charge differentially for reasons other than age (a 3:1 maximum iirc).

  5. This has been a huge national problem, especially since the development of alcohol screening and brief intervention which has been shown in research to be successful in helping patients who drink too much. Information about efforts to change state laws can be found at

    I'm not clear what you mean by ACA, but if it addresses the problem of insurers denying coverage I need to know more about it to inform those who are working to change state laws. Please say more.

  6. Mark — if memory serves ACA did not pre-empt these laws. What we got was that an individual could not be denied the issuing of insurance due to an alcohol problem, e.g., The fact that you were in alcohol treatment 2 years ago can no longer be used as a reason for an insurance company to not sell you a policy. But that is legally different than whether a state can allow denial of payment for a specific service in cases of acute intoxication for someone who already has insurance.

  7. The impact of ACA on laws like this will likely depend on how minimum levels of benefit are defined, and what is considered to be an acceptable exclusion. Actually, I think there is probably a decent argument that, at least for emergency services, this clause would be illegal in many states.

  8. Paul, the exclusion relates to injury that is a result of illegal activity — not the use or misuse of legal substances. It wouldn't be enough to show that someone was drinking while driving — but that they had a blood alcohol level higher than the law allows. You can assume that everyone but insurers hates these exclusions and makes it difficult for insurers to enforce them.

  9. If your insurance company were to rescind your policy saying you'd violated the terms, couldn't you immediately get the policy anew by declaring damage from your past behavior a preexisting condition?

  10. We seem to be confusing the denial of coverage to a person and the denial of coverage for a course of treatment. ACA deals with the first; for the second, the U.S. tradition is to legislate on a case-by-case basis. Breast reconstruction, mental health care, contraception come to mind.

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