Drug treatment: how to separate the good from the bad.

• Author: Humphreys, Keith
• Position: Special Report on Mental Health

In the movie Annie Hall, Woody Allen's character tells an old joke about two elderly ladies at a Catskill mountain resort: "One of 'em says, 'Boy, the food at this place is really terrible.' The other one

says, 'Yeah, I know--and such small portions.'" Well, the good news, when it comes to addiction treatment policy, is that the portions are larger--that is, reforms over the past decade have made treatment for substance use disorders accessible and affordable to more Americans than ever. The bad news is that the quality of much of that care is still terrible.

Even before the overdose crisis began claiming as many lives each year as AIDS did at its peak, the need for substance use disorder treatment in the United States was immense. More than twenty million Americans meet medical diagnostic criteria for a drug or alcohol disorder, exacting a brutal toll on their health and well-being as well as imposing substantial costs on the community, from intoxicated driving, violence, unemployment, family breakdown, and infectious-disease transmission. But because excessive substance use has until recent years been seen primarily as a sin meriting stigma and punishment, funding for addiction treatment has been in short supply. Many private employers haven't particularly wanted to provide good insurance benefits for their employees wrestling with addiction, and taxpayers have been reluctant to fund services, with the exception of a few groups who provoke unusual sympathy and concern, like veterans and pregnant women.

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However, sustained cultural and political activism, including by recovering addicts themselves, has created a new public understanding of substance use disorder and, with it, a new public policy environment. In 2008, Congress, with strong bipartisan majorities, passed the Wellstone-Domenici Mental Health Parity and Addiction Equity Act, which mandates that substance use and mental health disorder treatment benefits provided by large employers be comparable to those provided for physical health care. The same year, the Medicare Improvement for Patients and Providers Act substantially enhanced the outpatient substance use and mental health disorder treatment benefits for that program's fifty million beneficiaries. The Affordable Care Act (ACA) advanced access even further in 2010 by mandating coverage for substance use disorder screening and treatment in health insurance exchanges and within the Medicaid expansion...