The Rarely Acknowledged Public Health Achievements of Obama’s Drug Policy

Obama’s health oriented drug policy reforms are underappreciated

After initially accusing President Obama’s outgoing drug policy director Gil Kerlikowske of opposing public health measures in drug policy, Eric Sterling had the class to publically acknowledge Kerlikowske’s health-oriented reforms:

[Kerlikowske] recognized the importance of stopping the spread of HIV/AIDS among injecting drug users and recognized their humanity and dignity in the way his predecessors did not. Second, in the same spirit, he recognized that the dissemination of naloxone into the environments of opiate users, many of whom are using drugs illegally, would stop overdoses from becoming fatal.

Sterling also praised Kerlikowske’s support of opiate substitution therapies (e.g., methadone maintenance), which the administration expanded within the Tri-Care insurance program for military personnel and their families and spread internationally through the President’s Emergency Plan For AIDS Relief (PEPFAR).

In addition to the points Sterling raised, one could also note that the Administration’s signature legislation — the Affordable Care Act — mandates full coverage in Medicaid and health insurance exchanges for addiction treatment. That’s the biggest stride the federal government has taken towards health-oriented drug policy in at least 40 years and probably ever.

Sterling’s explanation for why his first article was inaccurate is powerfully honest and important:

I insulted Mr. Kerlikowske and dismissed his record on matters I did not review, relying on prejudices I formed regarding other subjects such as drug “legalization,” whether the Administration’s anti-drug program was “balanced,” as he claimed, and on marijuana policy. I deeply regret that I was unfair to Mr. Kerlikowske and misled the readers of Huffington Post regarding his support and commitment on important public health issues.

Sterling was by no means alone in his assumption that anyone who opposes drug legalization also opposes health oriented drug policy reform. But historically and cross-culturally, opinions on those two matters have not intersected in a consistent way. For example, among the people who identify themselves as “harm reductionists” around the world are many individuals who want all drugs legalized and many individuals who regard that idea with terror and hostility (Mainly because of the experience of legal tobacco). Among people who support legalization are individuals who favor increased availability of addiction treatment and individuals who are quite skeptical of the addiction treatment enterprise. And among people who oppose drug legalization –President Obama being a prominent example — are individuals who want to augment the quantity and quality of health services for drug users. Continue reading “The Rarely Acknowledged Public Health Achievements of Obama’s Drug Policy”

Yet Another Way to Misunderstand President Obama’s Record on Addiction Treatment

President Obama has done more to expand the quantity and quality of addiction treatment than any President in at least 40 years, but you wouldn’t know it from much of the coverage his drug policy receives. In the latest critique, Rebecca McCray and Emma Andersson praise the public health rhetoric of White House drug policy director Kerlikowske but are disappointed to find only a small increase in treatment funding in the President’s FY13 federal drug control budget. I applaud McCray and Andersson’s public health advocacy, but they are misunderstanding something quite important about how health care is financed relative to other components of drug policy.

Their analytic error is not as serious as those which have plagued similar criticisms of the President: John McWhorter condemned the lack of treatment funding in the Department of Education, which doesn’t fund healthcare, while Mike Riggs completely missed the significance of (indeed, didn’t even mention) the Affordable Care Act. Nonetheless, McCray and Andersson’s mistake is worth pointing out because it supports an inaccurate and unfair conclusion about the President’s drug treatment policy.

For most categories of spending in the federal drug control budget, government dollars are 100% of total expenditures. Only the federal government has Coast Guard cutters intercepting cocaine-filled powerboats in the Caribbean. Likewise, only the federal government provides the budget of the courts in which drug traffickers are tried and convicted. Therefore, if you want to know how much is being spent on these sorts of drug policies, all you have to do is tally up what the government is spending as does the federal drug control budget.

In contrast, billions of private dollars are spent on addiction treatment each year. Federal policies that increase the amount of those dollars, for example by mandating that insurers cover addiction treatment, don’t show up in the federal drug budget. Indeed, a pro-treatment federal government policy could even reduce treatment expenditures in the federal drug control budget if the policy enabled addicted people to access privately funded care instead of publicly funded care.

For example, one of the reasons those of us who worked on the substance use disorder-related provisions of the Affordable Care Act are pleased with the legislation is that it allows parents to keep children on the family health insurance policy until the age of 26. Because the early 20s are high-risk years for the incidence of addiction, the ACA thus expands drug treatment coverage to a high-need population. How much of the spending on treatment received by young adults because of this new federal policy shows up in the federal drug control budget? None of it, because it’s private money. The President’s policy drives the increase in private sector spending but that’s irrelevant in the calculation of the federal drug control budget, which only reports public expenditures.

As the ACA is phased in, its provisions will drive much more private money into addiction treatment provision. That’s because the legislation requires the privately financed policies offered in the state health exchanges to fully cover addiction treatment at parity with treatment for other conditions.

To quote the mandarin Harold Pollack, whom everyone who writes one of these misleading articles about the President’s drug treatment policy ought to consult before going to press: Wonderfully, the Obama administration has quietly revolutionized financing of addiction services. This change is readily overlooked because it occurs outside the $15.5 billion “National Drug Control Budget”.