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Legislating Insurance Parity for Addiction Treatment

The attitude toward addiction has led to discrimination in many ways, particularly when it comes to health insurance coverage for treatment. "We know that alcohol and drug addiction is a disease, yet we still have not integrated it into the health insurance system in a way that is meaningful," says William McColl, director of government relations for the National Association of Alcoholism and Drug Abuse Counselors. "People run out of benefits too early," he explains.

Protesters in favor of treatment

Advocates for better access to addiction treatment are beginning to take political action.

Many insurers have been reluctant to provide the same coverage for treatment of substance abuse dependence as they do for other diseases such as hypertension and diabetes, because of fear of costs and ambivalence about the efficacy of treatment. Employers -- who pay the premium for health benefits -- also worry that providing such relief would be too costly.

If addiction treatment is covered, often there is a cap on how long or how many times one can receive services. Critics of these policies say that isn't the way other chronic diseases are covered, and isn't fair -- or effective. "No one would say, 'Well, sorry, you've had your chance, and you can't try to quit again [to someone who is trying to quit smoking]; but we turn to the person who is addicted to illicit substances, and there's a tendency to say, 'Well, you're limited in the number of times in which you can try to quit, because if you haven't succeeded after the first or second time, there's something the matter with you,'" says Dr. Lonnie Bristow of the Physician Leadership on National Drug Policy. Addicted people shouldn't have to "jump hoops" to get treatment if they want it, he says.  "We've got to bring that same understanding of the human condition that we have for legal substances to the abuser of illicit substances."

Norman Hoffmann, who directs policy programs at the Center for Alcohol and Addiction Studies at Brown University, has been assessing addiction treatment outcomes. He says it's a misconception that one-shot treatment alone should be expected to result in lasting recovery. "The duration of maintenance care services immediately following a primary treatment episode has a very marked and significant influence on outcome," Hoffmann says. If a patient doesn't get any maintenance care, the odds of sobriety for a year are less than 40 percent. If they get maintenance care, the odds of being abstinent for a year rise, he says. But coverage that provides for anything less than three months of maintenance, "is essentially useless," Hoffmann says. He says the findings should help purchasers when deciding on coverage for their workers and how to manage addiction treatment services in the workforce. Like any chronic illness, he says, addiction is a disease that requires maintenance therapy. "You don't get aftercare with diabetes, you get maintenance care. It's expected that you'll see a professional from time to time for the rest of your life. To date, we haven't seen that mentality for addictions, even though it's a similar affliction."

Managed care has made it harder for addicted people to gain access to treatment, says Dr. Herbert Kleber, executive vice president and medical director of the National Center on Addiction and Substance Abuse (CASA) at Columbia University in New York. Particularly for inpatient care, patients often have to go through a variety of gatekeepers before they can get approved. And, finding effective treatment is another challenge. "Many [programs] have been so decimated by managed care, it's hard to find really good ones," says Kleber.

Insurers also typically limit the length and number of treatment services provided. For some hard-core addicts who not only need comprehensive treatment but also training in basic life skills to function in society and avoid relapse, this is a particular problem. "For those people, giving them drug or alcohol treatment is not going to be enough," says Kleber. "They often need intensive, long term treatment." Despite the fact that such intensive treatment has been proven effective in reducing crime and improving social adjustment, Kleber says, society has been short-sighted. "We are often so busy looking at how we can shorten and cheapen treatment that we fail to look at how effectively a really comprehensive treatment can be," he says.

Representative Jim Ramstad

U.S. Representative Jim Ramstad (R-MN) has introduced legislation to improve insurance coverage of addiction treatment.

A bipartisan pair of congressmen has recently introduced legislation that would force private insurers to cover addictive disorders just as they do other illnesses. Sen. Paul Wellstone (D-MN) and Rep. Jim Ramstad (R-MN) are trying to make treatment more accessible and bar private insurers that already cover substance abuse treatment from imposing spending caps, deductibles, and high co-payments for substance abuse treatment that aren't imposed on treatments for other chronic illnesses.

The effort is similar to the campaign waged last year by the mental health community, which was trying to put mental illness coverage on par with physical illness. A report released late last year and underwritten by treatment advocates found that equalizing treatment coverage would increase insurance premiums by less than $1 per month per subscriber.

Although these lawmakers are committed to seeking parity for health coverage of alcoholics and drug addicts, even their most ardent supporters admit that they face an uphill battle. Insurers and employers are likely to oppose a parity bill on the grounds that it would be too expensive (despite the fact that addiction to alcohol, tobacco and illicit drugs costs hundreds of billions in lost productivity and health costs). And because of the stigma that is still attached to addiction, there is no national consumer group for alcoholics and drug addicts. "No one is stepping up and speaking out," says McColl, "so we haven't tapped into the potential power of people saying 'this is a problem for us.'" Unlike advocates for mental health parity, then, advocates for addiction coverage parity don't have much congressional muscle behind their cause.

Ramstad admits that many of his Capitol Hill colleagues don't understand the disease of drug addiction. Politicians have to hear and accept the message that putting more money into dealing with treatment and prevention will produce better results than locking up people with a drug problem, he says, but the field has a massive education job to do to accomplish that goal. Join Together reports that offenders' illegal drug activity in California dropped 43.3 percent after they received treatment; Illinois found that offenders who received treatment while incarcerated and after release committed significantly less crime than other offenders; a study of employees who underwent substance abuse treatment found an abstinent rate of more than 60 percent after a year. Treatment also is less expensive than interdiction, enforcement and prosecution. Incarcerating an adult for a year costs up to $37,000, whereas residential substance abuse treatment costs about $14,600 and outpatient treatment costs an average of $2,300.

McColl says policymakers have to realize that changing the law is important. Treatment has become more restrictive, and people are trying desperate means to get in. Many of those addicted to alcohol and drugs in the U.S. who go untreated cannot afford to pay for treatment or have inadequate or no insurance to cover costs. But even among the insured, substance abuse treatment is increasingly unavailable. "I've heard families say that the only way you get treatment is if you threaten suicide or threaten others," he says.

-- Janet Firshein

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