I found some interesting info in the National Survey on Drug Use and Health (NSDUH) reports today, and made a table with it. It lists the 4 major types of treatment, and the percentage of their revenue which comes from public sources.
On average, these facilities are collecting 69.5% of their revenue from some form of government (source). Another NSDUH report shows us what sources individuals are using to pay for treatment.
Many people are using 2 or more sources, like a combination of private payment and insurance, or insurance and medicaid. If you look at the third column in the table above you’ll see that with the combined sources of Medicare, Medicaid, Public Assistance Programs, and Court funding – 51.7% of people have used public funds to pay for their most recent trip to the treatment center (source). So we have 2 important facts here:
- More than half of people who get treatment (51.7%) are using public funds to pay for it.
- With the average treatment program getting 69.5% of it’s revenue from public sources, government is definitely paying the lion’s share of dollars spent on these horrible programs.
These facts then lead us to a conclusion: Treatment for addiction does not exist within a free market. There is no way to call a market in which half of the consumers are being directly funded by the government to purchase a specific service (conventional disease model addiction treatment with 12-step components), and nearly 3/4 of revenues in said market are flowing from government sources. There is simply no way that we could consider help for addiction as existing within a free market. I bring this up, not to push my own libertarian agenda, but to push my addiction agenda. There are some wonderful people out there with real solutions to substance use problems, and I believe their methods would spread quickly in a competitive market – unfortunately though, the ineffective conventional methods of treating substance use problems are propped up by government funding. Without this funding, they would be forced to change their methods and offer a service that was worth the money, but they are insulated from this competitive force by government. Imagine laying out 20 grand for a treatment program in which your loved one came back worse than before they started it – you’d be pissed, you’d want answers, you might demand a refund, and you would definitely be less likely to try the same type of program again. But if the public is footing the bill, you won’t take it as seriously. Now imagine that there are tens of millions of people like you, all laying out their own money for a treatment program. This would have a big effect on the industry, they would either change their ways, or lose customers and go out of business.
I can’t tell you how many times I’ve been called on by friends and family members to talk to someone’s parents about sending them to the program I went through – and I can’t tell you how often people choose a conventional treatment program because the state or their insurance company will pay for it. The program I recommend doesn’t get this type of funding, because they’ve opted to take a different non-medical approach – and it pains me to see people choose a program that will do them harm just because they don’t have to pay out of pocket for it (some follow my recommendation, and I’ve been thanked and praised often for the advice). The saddest part is that the state or insurance funded program will probably cost them more in the long run – in the way of a constant struggle of being “in recovery”, time, relationships, and other resources lost to protracted episodes of substance abuse, and repeated trips to a string of further treatment programs. It’s not that I want people to go broke paying for help, it’s that I want them to get real help, and as long as government is this heavily involved in “treatment”, they’ll only find disappointment where they’re currently seeking help.
There is no free market for addiction treatment, and the source of the dollars spent on it is enough evidence of that – but this is all without mentioning the influence and money the government wields through agencies such as SAMHSA, NIAAA, NIDA, CDC, and countless state regulatory agencies to propagate the idea that addiction is a brain disease which robs people of their free will and thus the ability to choose to stop. Is there anyone else out there in the marketplace of ideas with even half as much influence and money who is using it to challenge these deeply entrenched myths our government is spreading? There are none that I know of.
Through these agencies (especially the NIDA), the government has spent billions of dollars on outreach and PR to convince the american public that addiction is a disease which requires a certain type of medical treatment. They run “public service” ad campaigns, print leaflets and distribute them to medical health providers, make news through press releases and congressional testimony, send representatives to spread the message through television shows and press interviews, and sponsor countless websites to disseminate the disease view. Now imagine that you are a business with the goal of helping people with substance use problems – essentially 100% of your potential customers have been taught by the government that addiction is a disease which requires a particular type of treatment. Moreover, 51.7% of your potential customers will be funded by the government to purchase help which corresponds with this view. Another 25.9% of your customers have insurance plans which state governments have mandated to pay for addiction treatment which falls in line with this view. Essentially, if you don’t follow the disease model favored by the government, you are turning down at least 69.5% of the revenue you could be taking in. Now, does it make any sense to go into the business of helping substance abusers offering a service which doesn’t follow the disease/medical treatment view of addiction?
NOTE: I want to clarify that the point of this post is not to complain that some people are getting free treatment provided by the government, or that some are being partially subsidized by the government, or to put down anyone who accepts such public assistance. My complaint is not about some sort of unfairness of some people having to pay for treatment while others get it for free. I have no personal disapproval for anyone who accepts this assistance. If the government is providing it, and thus it is basically costing all of us (in one way or another) then from a financial perspective at least, it is rational to take advantage of it (although, it’s irrational to attend these programs since they simply don’t work!). My points are as follows:
- The government is subsidizing and rewarding failure on the part of treatment providers.
- The government is promoting a model of addiction & recovery which was politically chosen rather than rationally/scientifically chosen. This hurts people by dictating the model a treatment program will use, and through PR efforts that spread the disease model, it hurts people who haven’t even been to treatment yet by convincing them of the faulty disease model.
- If we didn’t have this situation, the market would be more competitive and the most effective methods of helping people with substance use problems would more likely rise to the top to become the new norm.
Your critique of current public health policy is largely spot on. The preferred treatments are ineffective, expensive, and overly politicized. It’s how you arrived at the conclusion that a “free market” solution is preferable that’s baffling me. There seems to be an ideological assumption that the “invisible hand” always makes private enterprise cheaper and more efficient, which is often not the case by the very nature of the profit motive. Sometimes the best way to address bad policy is to change it through public institutions or by drafting better policies based on proven best practices.
Agreed, the disease model is specious, 12-step programs encourage people to make a lifelong commitment to trade their agency for being clean/sober, many are state-funded religious indoctrination, and empirical data shows that the favored treatment methods have obscenely high relapse rates (AA/NA, rapid outpatient detox, brief in-patient/residential stays, lack of psychological & vocational support concurrent with and consecutive to primary treatment).
However, the reason the treatments are favored is that they are cheap, and the disease model is favored because it puts a legal onus on insurance providers (public & private) to cover treatment. There will never, ever be a “free market” in the health care industry, thank goodness, because various kinds of regulation, from the safety oversight functions the FDA is supposed to provide to certifying physicians to addressing issues of common concern (i.e. preventing pandemics) to preventing fraud are all required in this critical sector.
Just because addiction and dependence aren’t diseases doesn’t mean they are choices per se. Physiological enslavement is probably how I’d describe it, with getting clean/sober being a liberation rather than a cure. Physical dependence is a biological reality, and addiction is a mix of physiological and psychological elements. If both addiction and dependence are not being addressed effectively, and if the circumstances of the addicts lives don’t change (changing friends, habits, routines, situations requiring an escape, underlying causes, finding steady work, etc.), then it is unlikely any treatment will take. Yes, they have to be ready and willing to change on a conscious and unconscious level, but to call it a choice makes it sound as though sheer will is the sole remedy.
Thanks for the engaging comments Austin.
While I prefer to stay away from a deep debate of free market ideology here, I’d still like to highlight that we obviously agree that addiction treatment doesn’t exist within a free market. I think the evidence which I’ve presented above is enough to convince anyone, whether or not they favor free markets, that indeed the treatment industry is not a free market. Health care in general is not a free market, with slightly more than 50% of healthcare dollars spent by government sources. We know that this market in general is a mess, but the situation in addiction treatment is even worse, with approximately 70% of funding coming from government sources.
To some readers who understand free-market ideology, these facts will be very significant. They will realize that the standard treatments are in place not because they’ve won out with customers by proving to be effective and worth the investment – but that they are the norm because they’ve won out politically, and that the powers that be will keep paying for people to go to these ineffective and expensive treatment centers. This realization gives us even more cause to question the methods being used and the common knowledge on the subject of addiction.
Some other readers will find the above points irrelevant, and that’s ok. As long as they stay away from sending people to programs which are ineffective and potentially harmful, and instead try to use my recommendations of alternative programs or books or some other effective option for ending a substance use problem (including figuring it out on their own as the vast majority do) – then I am happy for them. I will stay sad for people who choose an ineffective program simply because the government will pay for it. I feel for them, and having been to the conventional programs myself, I worry about the unnecessary struggle they may go through.
-Steven Slate
Thank you for the critique of the current system. Clearly, all ideology aside, those public (& private) funds are being wasted, and those seeking help are poorly served. While we may differ on how best to do so, I share your hope that the disease model will be debunked, and compassion for people seeking to change their life for the better through flawed techniques.
The Latin etymology of “addiction” is “enslavement”, which I think is apt. One major psychological side-effect of addiction is “learned helplessness”, feeling robbed of agency due to repeated failed attempts to exert it. Any treatment of addiction/dependence must contain an element of liberation and self-empowerment as a bulwark against relapse. It’s certainly preferable to being 20 years sober and still identifying as an alcoholic that is powerless over their disease.
Finally, though you may be already, I’d recommend following the discussion of the DSM-V revisions of addiction/dependence. While I feel that the disease model is scientifically invalid in almost all areas of so-called mental health, the DSM-V will provide the legal and clinical basis for all public and private insurance and treatment when it is published (US & abroad): http://www.dsm5.org/ProposedRevisions/Pages/Substance-RelatedDisorders.aspx
The treatment industry started with a political movement designed to control people which was based in morality, not in science. And while there are many ideas in Austin’s comment with which I take issue probably the greatest misinformation he cites is that the government promotes and provides this kind of treatment modality because it is cheap. To the contrary, the disease based treatment modality is a multi-billion dollar business. I would recommend researching the alternative approaches that you have mentioned here on this blog as he would find there are much less costly and much more effective ways to help people overcome a drug and alcohol problem. As always, great article! Thanks for your post.
Thanks Michelle. It was started politically, and I did a ton of research about the origins of the disease concept and public acceptance of it back when I first started writing my (still incomplete) book. Maybe I’ll dig some of that up and do a post on it. As I recall, a good source of info on it is the NCADD’s (Marty Mann of AA fame’s organization) own website, where they basically brag about the fact that their main goal was to gain acceptance of the disease concept and how they enlisted celebrities and eventually elected politicians to do so – and further, that they were able to kickstart the treatment industry in a big way by getting politicians to allocate government dollars for it. The funny thing about the information found on their site is that it shows they started not with scientific knowledge, but only with a goal of swaying public opinion. Then they eventually tried to back it up with some science, and as we know, their work with Jelinek was highly suspect, and certainly not scientifically sound. Then, after 40 or 50 years of telling people to get treatment for the “disease” they decided to look into whether treatment was actually effective, and they found that it was an ineffective mess! But it hasn’t stopped them from continuing to push their agenda!
Both government and industry are incredibly short-sighted when setting policy. Government policy is often ruled by election cycles, campaign fund-raising, the influence of lobbies, fiscal year budgeting, institutionalized obsolete science, and unreliable funding year-to-year. Big business is legally compelled to maximize shareholder returns, which leads to a focus on quarterly returns and annual net profits. Neither seems very good at long term planning at the moment.
Take opiate addiction/dependence. In the short term, a 21-day outpatient methadone detox is cheaper than 2 years of methadone maintenance in tandem with counseling, lifestyle changes, and vocational training (if needed) before starting detox. In the long term, the cheapest treatment is the one that works, because it closes the cycle of endless “recovery” and relapse. Aspects of physical dependence will vary by substance, but psychological addiction is frequently (thematically) similar.
How exactly am I misinformed? Or do you simply disagree? Please direct me to a specific post, if that would help. The disease model is not just wrong, it’s perpetuation is harmful to both individuals and society, in addition to the expense. However, any alternative that is not covered by insurance (private and/or public) is academic, as most addicts (including high functioning ones) will not save enough surplus income to pay entirely out of pocket.
While I have not yet completed a piece on actual treatment costs for this site, one example comes to mind. Project MATCH compared a few different types of treatment. Here’s what Stanton Peele has to say about the findings:
“since motivational enhancement is a brief therapy (in MATCH it comprised four sessions or fewer, compared with 12 sessions for 12-step and coping skills therapy), it supposedly would not be as successful for severely dependent alcoholics.
In fact, motivational therapy was as effective for all alcoholics treated in the study! And it was the cheapest and least intensive therapy.” Source: http://www.peele.net/faq/motivational.html
4 vs 12 sessions – the most basic math would put MET at 1/3 the cost of the average 12 step infused treatment methods. While these and similar techniques have been brought into more mainstream use over the past decade, they exist alongside and in conjunction with 12-step methods which somewhat defeats the purpose (that is, the same treatment centers which claim to be using something such as 12-step facilitation most of the time, also claim to be using motivational interviewing or MET most of the time – so they’re probably using both concurrently in a good proportion of cases). Moreover, the 12-step based methods of substance abuse counseling still have a stranglehold on the treatment industry.
BTW – Keep in mind that with Project MATCH, there was no control group of untreated alcohol abusers. It only represents some methods of treatment compared with other methods of treatment, and does not account for rates of natural recovery which occur in the absence of treatment. Nevertheless, what we can take from it is that even though they know that within their scope of practices they could cut their contact with patients and consequently their costs by two thirds, and remain as effective as they ever were – they’re still sticking with the more intensive models of treatment. It’s bewildering, but then when you consider that government forces which are resistant to change and only need to show that they’re paying for treatment to make people happy, are still paying for treatment which is three times more costly than it needs to be – it becomes far less bewildering.
This is exactly why, as a citizen, I am very concerned about the whole”recovery” movement -it has insinuated itself not only into our culture, but into our government – both as something that is seen by many citizens as something we are obligated to pay for, and also as a now integral part of the justice system. Drug & alcohol testing of defendants is now routine in all sorts of cases – many with no relation to drug transactions or driving under the influence. Twelve set programs seem to be a requirement in prisons (at least from what I’ve seen sampling reality prison shows on several networks showing prisons for men, women, juveniles in various locations, as well as watching parole hearings on cable access in which people claim to have taken responsibility for their lives by admitting they have addictions that preclude responsibility for their actions – it would be funny, it it weren’t so sad).
Outside the justice system, there’s a bigger issue for U.S. taxpayers – that is the rise of “mental health parity” for health insurance requiring health insurers to cover mental health – including substance abuse – expenses as fully as they cover physical diseases. When you consider that the definition of addiction/alcoholism is that it lifelong & incurable, with lots of relapses, and that there’s no scientific way to determine whether someone actually needs the “treatment” or when they’ve had as much as will actually help them (unlike physical conditions where they can determine that while X operation is possible, the chances of it improving functioning are less than 10%), combining “mental health parity” coverage with the completely unscientific construction of addiction/recovery is a recipe for bankrupting the country without even having to go to war against another country.
Also considering how many people have turned their irresponsible life histories into careers as “addiction counselors”, there are a lot of people who will be available to petition for funds to go to “addiction treatment” & raising a ruckus is funding is not forthcoming or is restricted our country has a big problem on its hands.