Barack Obama ran for president offering “change,” and he promised that comprehensive reform of the nation’s health care system would be a top priority. In his first address to Congress, President Obama said, “[T]he cost of health care has weighed down our economy and the conscience of our nation long enough. So let there be no doubt: Health care reform cannot wait, it must not wait, and it will not wait another year.” Health care reform is already well underway. For advocates concerned about addiction prevention, treatment and recovery support, reform offers a unique opportunity to expand the services that reduce drug use and help people recover. Yet it is also poses some significant challenges to overcome.

There is broad political consensus that our current health care system needs an overhaul. The U.S. spends 16 percent of its total economy--$2.2 trillion annually—on health care. Health insurance premiums are increasing far faster than wages (they jumped 78% between 2002 and 2007), putting a strain on both families and businesses. At the same time, the federal government and the states are spending more and more on health care, and this trend is expected to get far worse as baby boomers begin to access Medicare. Adding insult to injury, despite such high levels of spending over 45 million Americans have no health insurance at all .

There has been no shortage of proposals put forth in recent years to ameliorate the problems with our health care system. These include de-coupling health insurance from employment (Sens. Wyden and Bennett), transitioning to a “single-payer” system (Rep. Conyers) and eliminating state-level regulation of insurance plans to encourage free-market competition (Sen. McCain).

The growing consensus, however, is that 2009’s health care reform will build upon the current system. Although the policy details are far from certain, this year’s proposal may look something like this: If you like your insurance, you can keep it. More employers will be required to provide health insurance for their workers (with tax credits to encourage them). If employers choose not to do so, they will be forced to pay into a fund that provides subsidies for individuals purchasing their own insurance. The federal government will operate an “insurance exchange” that essentially provides an organized, regulated market from which individuals or businesses can purchase private insurance (or, perhaps, choose a new government-run insurance plan). Plans within this exchange will have to meet certain minimal standards, such as non-discrimination against pre-existing conditions. Tax credits will enable people who are currently uninsured to purchase a plan. There will also be a limited expansion of public health care programs, a process that began earlier this year when Congress enabled four million more uninsured children to enroll in the Children’s Health Insurance Program.

Health care reform legislation is also likely to include various measures to increase efficiency and reduce costs. Health information technology (IT) will be expanded, with greater integration of electronic health systems. More data will be collected by providers, and there will be closer scrutiny of outcome measures. Steps will be taken to reduce fraud and waste in public programs. Although there is no agreement on how to pay for these reforms, the legislation will address that issue as well.

Advocates for addiction services have a strong case that the effects of addiction within our health care system are too significant to be ignored. One-quarter of all deaths are traceable to drugs, alcohol or tobacco. There are 1.7 million emergency room visits each year where alcohol or drugs are the primary cause. Dozens of health problems, from many cancers to heart disease to cirrhosis to HIV to accidents to acts of violence, are can be traced to or transmitted because of drug or alcohol use. This does not even begin to account for the “spillover” costs of addiction on families, the criminal justice system, workplace absenteeism, or the many other areas of society affected by addiction.

Advocacy during health care reform poses numerous challenges. From 2007 - 2008, the health care sector spent about $1 billion on lobbying and nearly $50 million in campaign contributions. Not only does every health care interest group want to influence health care reform, but nearly every other sector of American society has a stake in the outcome as well. The compressed timeline puts extra pressure on advocates as well.

Although the data is undeniable, lingering stigma and the crowded advocacy environment can make it difficult to educate policymakers about addiction’s true role in the health care and how reform legislation might address it. Perhaps one of the most effective ways to bring addiction to the fore of the debate is to speak about it in a way that shows how addiction relates to some of the “frameworks” in which health care reform is currently being discussed by policymakers. Three of the leading concerns are chronic disease management, integrated care and prevention.

Chronic diseases have received enormous attention because they are so expensive and have such long-term health costs. Addiction is one of America’s most prevalent chronic diseases (over 23 million people have a substance use disorder, whereas 16 million have coronary heart disease, 15 million have diabetes and 5 million have Alzheimer’s). Research has shown that addiction treatment is equally or more effective than treatment for other chronic diseases. The cost effectiveness of addiction treatment is also well demonstrated, with savings up to $7 – 12 for each $1 spent. Speaking about addiction as a chronic disease also enables advocates to make the case for long-term recovery support services.

There is also much discussion in Washington about the need to better integrate our health care system to improve outcomes and reduce redundancy and medical errors. Health IT is one mechanism to achieve this, and advocates must ensure that addiction treatment programs can be part of the national health IT network (while respecting the confidentiality needs associated with addiction). To be left out of health IT would relegate addiction services to an isolated, parallel system. Reformers are also looking at structural models that improve care coordination. One model is the “medical home,” wherein a provider (often a primary care physician) is assigned as the point-person for all the various specialty care a patient receives. Because so addiction so frequently co-occurs with other physical or mental conditions, advocates have an important message to share about how treatment should fit in to a medical home or other coordinated care model. Expanding initiatives like screening and brief intervention also fits within the coordinated care framework.

A third major framework of the health care reform debate is prevention. For advocates of addiction services, this includes not only educational outreach and community engagement, but also the idea that treating addiction prevents the onset of other debilitating, expensive health conditions. But the framework of prevention can be expanded even further. We know more and more about the costs of addiction on families. Over a quarter of all children grow up with substance abuse in their homes, and these children have been found to be at heightened risk for a large number of physical, mental and social problems including suicide, teen pregnancy and substance use disorders of their own. The prevention framework allows advocates to talk about the benefits of family treatment as well as the supports and interventions that prevent relapse itself.

Procedurally, health care reform will be driven by two Senate committees, Finance and Health, Education, Labor & Pensions. Both committees have set mid-summer as a goal for completing their respective legislation, which would then go to the full Senate and House of Representatives. Whether this timetable is ultimately achievable remains to be seen. Nonetheless, it leaves advocates with little time to make their case. For more information about the health care reform debate and ideas for how you can get involved, please visit www.naadac.org/advocacy.

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