[Congressional Record Volume 140, Number 11 (Tuesday, February 8, 1994)]
[Extensions of Remarks]
[Page E]
From the Congressional Record Online through the Government Printing Office [www.gpo.gov]


[Congressional Record: February 8, 1994]
From the Congressional Record Online via GPO Access [wais.access.gpo.gov]

 
       HAROLD E. HUGHES ADDRESSES THE PROBLEM OF SUBSTANCE ABUSE

                                 ______


                            HON. NEAL SMITH

                                of iowa

                    in the house of representatives

                       Tuesday, February 8, 1994

  Mr. SMITH of Iowa. Mr. Speaker, all Americans either have or should 
have become acutely aware of the major problems associated with the use 
of, dependency on, and abuse in the use of substances. These problems 
not only affect our economic and physical health both as individuals 
and collectively, but also are reflected in a large way in Government 
expenditures.
  A former Governor of Iowa and former Senator from Iowa, Harold E. 
Hughes, is a recognized expert and leader concerning this subject.
  On last Friday, he appeared before the Ways and Means Subcommittee 
which is holding hearings on proposed legislation dealing with this and 
other health care subjects. So that those who have access to the 
Congressional Record either directly or in the Nation's libraries may 
have an opportunity to read this testimony, I am having it printed in 
the Congressional Record.

 Testimony of Former Senator Harold E. Hughes, Founder and Chairman of 
Society of Americans for Recovery, Before U.S. House of Representatives 
  Subcommittee on Health, Hon. Pete Stark, Chairman, February 4, 1994

       Mr. Chairman, I am grateful and honored to appear here 
     today on behalf of the millions of Americans who suffer from 
     addiction disease; on behalf of all Americans, who as 
     taxpayers pay an extraordinary percentage of our income to 
     support untreated additions; and specifically on behalf of 
     the seven to ten million Americans who today have moved 
     beyond their personal addiction histories and enjoy new life 
     in what we know as recovery.
       I am a qualified representative of each of these 
     communities. Many of you are familiar with my story, much of 
     which is public record. I have experienced life at both ends 
     of the spectrum: I was incarcerated in six states for 
     behavior connected with my addiction, and I served six years 
     as Iowa's United States Senator across the Hill here. Next 
     week, I commemorate 40 years of abstinence from my drug of 
     choice, which is alcohol.
       We consider here today an opportunity of profound impact on 
     all who suffer from chemical dependency, and all Americans 
     who are touched by the grief, the terror, and the cost of 
     these diseases. We have the opportunity to take the third and 
     most important step in history toward conquering a plague--
     and demolishing a pernicious myth--that has deformed mankind 
     since the beginning of civilization.
       If we as a nation take this step, I will have lived to 
     experience each of these historic steps.
       The fist major step was the founding of Alcoholics 
     Anonymous in 1935. The ability of one alcoholic to be in 
     service to another, thereby penetrating the wall of 
     isolation, fear, and denial associated with the alcoholic 
     obsession, generated a new hope for alcoholics and their 
     families.
       Alcoholics Anonymous has been called the greatest spiritual 
     movement of the 20th Century. But equally important, the 
     success of this movement has impacted psychology, sociology, 
     and medicine, in broadly promoting the understanding of 
     addiction as a primary, chronic disease, not a bad habit.
       In 1970, I was happy and proud to be a channel for our 
     nation to acknowledge for the first time the disease nature 
     of addiction. The Hughes Act established a federal role for 
     attention to alcohol and drug dependency. It also fostered 
     development of treatment and prevention disciplines in the 
     private sector. This was the second great step forward for 
     America and its attitudes toward addiction disease.
       The advent of national health care reform offers a unique 
     and timely opportunity for America to make the third and most 
     important step: To face addiction disease as a major public 
     health threat and provide this nation with an appropriate 
     public health response.
       The nature, scale, and consequences of untreated addiction 
     in our society can no longer be held at bay by programs 
     driven by social conscience or the politics of ``doing 
     good.'' Instead, we must face hard economic and social 
     realities:
       There will be no reductions in our soaring cost of health 
     care until we attend to the nearly $300 billion annual cost 
     we as a society tolerate for the consequences of untreated 
     addiction.\1\
---------------------------------------------------------------------------
     Footnotes at the end of article.
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       Let me share with you a little of the economics of 
     addiction disease.
       While most Americans have ambivalent attitudes--at best--
     and erroneous or incomplete knowledge of addiction disease, 
     the facts speak bluntly: Untreated addiction disease in 
     America today is a major health disaster. We are the 
     earthquake in the health care scenario.
       There are approximately 18 million alcoholics and 6 million 
     drug addicts in the United States today.\2\
       Alcohol and drugs are the number-one cause of illness, 
     injury, and death in the United States\3\. Alcohol is a 
     factor in approximately half of all homicides, suicides, and 
     motor vehicle fatalities.\4\ Deaths from alcohol-related 
     causes took an average of 28 years from each victim's 
     life.\5\ Alcohol abuse and dependence is the most common 
     chronic illness between the ages of 18 and 44; drug abuse and 
     dependence is the second.\6\
       From 25 to 40 percent of patients in general hospital beds 
     are being treated for complications of alcoholism. Seventy-
     five percent of trauma victims test positive for drug use.\7\
       The majority of people in our jails and prisons today are 
     drug abusers or addicts. The link between drugs and crime is 
     especially clear: more than 80 percent of all incarcerated 
     people under the age of 35 are illicit drug users,\8\ and 61 
     percent of all federal prisoners are drug offenders.\9\ 
     Incarceration alone costs us over $7 billion. All together, 
     alcohol and drug abuse and addiction cost us $43 billion in 
     legal and indirect costs other than health care (see table 
     1).\10\
       Fetal alcohol syndrome affects nearly 2 in every 1,000 
     American births and as many as 25% of all Native American 
     births. The direct cost of treating these baby victims is 
     about $75 million. Between 350,000 and 625,000 infants are 
     drug-exposed each year. Indirect costs for those infants, 
     including lost worker productivity, will reach $1.4 billion 
     by 1997.\11\
       Twenty percent of all AIDS cases in the United States today 
     and 20 percent of the costs to care for those people (about 
     $13 billion in 1991), are the result of intravenous drug use. 
     And that proportion is growing.\12\
       These numbers reflect only glimpses of the drain on our 
     society that addiction in America perpetrates. A rational, 
     comprehensive national treatment program is our key to a 
     stable economy, the reduction of health care costs, the 
     return of large segments of our labor force to productivity 
     (and the related decrease in the welfare rolls), the control 
     of crime in our communities, and the elimination of runaway 
     violence.
       This is not a job for America to face after we have solved 
     the really big problems of health care, economic growth, and 
     crime. It is a job that must be faced in order to reach our 
     goals of universal health care, sustained economic growth, 
     and safety in our homes, schools, and streets.
       As a society, however, we balk at facing these facts. Why 
     this reticence? Why this denial? Why do we Americans prefer 
     to tolerate unbelievable costs, unspeakable behavior, and 
     unconscionable human waste to support the most addicted 
     society on the face of the earth?
       To shed some light on these questions, consider the 
     politics surrounding addiction disease.
       While alcoholic beverages pre-date recorded history, the 
     invention of distillation in the 14th century made possible 
     increased concentrations alcohol--from 14 percent to more 
     than 50 percent. The introduction of spirits such as gin, 
     whiskey, and scotch soon caused much higher levels of abuse 
     and alcoholism and the social problems that go along with 
     them.
       The stigma often associated with alcoholism was firmly 
     enshrined in 1609 with the first attempt to legislate 
     moderation in drinking. The English Parliament passed in that 
     year an ``Act To Repress the Odious and Loathsome Sin of 
     Drunkenness.''

   TABLE 1.--LEGAL AND INDIRECT COSTS (OTHER THAN HEALTH CARE) DUE TO   
                     ALCOHOL AND OTHER DRUG PROBLEMS                    
                          [Dollars in millions]                         
------------------------------------------------------------------------
                                                             Type of    
                                                         substance abuse
                     Type of cost                      -----------------
                                                                  Other 
                                                        Alcohol   drugs 
------------------------------------------------------------------------
Criminal justice system:                                                
  Police protection...................................   $1,338   $5,810
  Legal and adjudication..............................      274    1,108
  State and Federal prisons...........................      884    2,130
  Local jails.........................................    1,238      460
                                                       -----------------
    Total CJS.........................................    3,734    9,508
                                                       =================
Drug traffic control:                                                   
  Prevention..........................................  .......      175
  Law enforcement.....................................  .......    1,380
                                                       -----------------
    Total drug traffic control........................  .......    1,555
                                                       =================
Other legal costs:                                                      
  Private legal defense...............................      342    1,381
  Property destruction................................      175      759
                                                       -----------------
    Total other legal costs...........................      517    2,140
                                                       =================
Other direct costs:                                                     
  Motor vehicle accidents.............................    2,584  .......
  Fire destruction....................................      457  .......
  Social welfare administration.......................       88        6
                                                       -----------------
    Total other direct costs..........................    3,129        6
                                                       =================
Indirect costs:                                                         
  Victims of crime....................................      465      842
  Incarceration.......................................    2,701    4,434
  Crime careers.......................................  .......   13,976
                                                       -----------------
    Total indirect costs..............................    3,166   19,252
                                                       -----------------
    Grand total.......................................   10,546   32,461
------------------------------------------------------------------------
Source: Rice et al., 1990.                                              

       Dr. Benjamin Rush, a signer of the Declaration of 
     Independence and a noted American physician, made a 
     significant medical breakthrough in 1785, though it was not 
     recognized as such at the time. His study led him to the 
     then-radical conclusion that once an ``appetite'' for spirits 
     had become fixed, the drinker was helpless. He suggested 
     total abstinence as a remedy.
       His findings, however, were ignored by the young nation, 
     who continued either to ignore alcoholism or to ``treat'' it 
     with righteous indignation and punitive measures, while 
     continuing to be puzzled at the lack of results.
       The seeds of our current crisis, however, stem from Dr. 
     Rush's experience. Truth will not be denied, although the 
     trail is often treacherous and misleading. The ``cure'' of 
     abstinence is such a truth.
       In 1919, we as a nation adopted the cure of abstinence--not 
     just for those afflicted with alcoholism, but for everyone. 
     The political disaster of this experience does not need to 
     be documented here. But let me rescue two ``truths'' from 
     this history which in their proper contexts are absolutely 
     necessary in the public policy debate of today.
       The first truth is that abstinence is the current best 
     solution for those individuals who suffer from addiction 
     disease. While severe abuse of chemicals can result in 
     addiction, most addiction is traceable to a biogenetic 
     predisposition. Suffering is triggered by consumption of an 
     addictive drug. But the condition is in place, and inherited.
       The second truth is that all citizens must participate in 
     solutions to addiction--not by participating in abstinence, 
     but in refusing to tolerate the high costs, unsocial 
     behavior, and archaic ignorance associated with alcoholism 
     and other drug addictions.
       The political reality and the factual reality are not in 
     line with each other. But I believe that they are closer than 
     most people think. And, I believe that action by this 
     Congress, based on clear, compelling, and accurate 
     information, can create a lasting solution and hope for our 
     nation.
       I believe Americans have assimilated many of the key facts 
     relating to addiction disease. There is great understanding 
     of the simple fact that while millions can safely drink 
     alcohol, approximately ten percent of our population lose any 
     ability to control use of chemical mood changers.
       I believe there is a greater climate for the reduction of 
     the stigma associated with addiction, together with an 
     acceptance of intervention techniques and less tolerance for 
     antisocial behaviors resulting from abusive and/or addictive 
     use.
       I believe average Americans are beginning to understand 
     wellness. More and more citizens know someone who is 
     recovering from addiction. Just as each practicing alcoholic 
     or addict affects an average of five other individuals, a 
     person living in recovery also affects others in a positive 
     way--demonstrating that wellness is achievable as well as 
     desirable.
       I believe American voters are tired of the politics of 
     denial. They will respond to the reality of helping 
     themselves by helping those in addiction.
       The President's initiative presents the Congress with a 
     unique opportunity to recraft health care as we know it. This 
     recrafting will be successful to the degree that we are 
     willing to look beyond myths and half-truths to seek solid 
     facts.
       One of the most important myths to expose is that treatment 
     for addiction disease is an expensive and ineffective ``add-
     on'' to health care that will send taxpayer's costs sky-high. 
     In fact, ``cherry picking'' by insurers and providers--the 
     selective offloading of people who have pre-existing 
     conditions or who simply change jobs--has obscured the 
     reality that treatment for alcoholism and other drug 
     addiction has been enormously successful and cost-effective. 
     The truth is that once providers are faced with the ultimate 
     costs of untreated diseases of any kind, prevention and early 
     treatment will become immensely popular. This will certainly 
     be true of addiction disease.
       Virtually all the literature consistently demonstrates that 
     total health care costs for untreated addicts are 
     significantly higher than for non-addicts, and those costs 
     ``ramp up'' at an extreme rate as the addict's untreated 
     disease grows more severe. But health care costs and costs to 
     society (for example, legal problems and problems on the job) 
     also decline significantly following treatment of alcoholism, 
     both for the chemically dependent person and for his or her 
     family.
       The average cost of alcoholism treatment can be recovered 
     within three years after treatment is initiated, in medical 
     utilization savings for the addict alone. And by four or five 
     years after treatment, health care costs for the treated 
     addict and family fall to lower than the average, and stay 
     there. In other words, the initial costs of treatment are 
     more than offset by the savings in health services not used.
       Our opportunity is to look at these facts now and to build 
     a public health response to addiction as we have historically 
     done for polio, heart disease, tuberculosis, and AIDS.
       This is not a feel-good or social benefit issue. At this 
     time, and in this climate, we ask for a hard-nosed, resource-
     based decision making.
       What this means is that the benefits package for addiction 
     disease cannot be the minimum level of care for today's 
     symptoms and behaviors. We must have a benefits package that 
     takes into account the life-long implications of untreated 
     addiction, the expensive deaths most of these lives entail, 
     and the proven savings in general health care utilization 
     that occur with high-impact, life-changing strategies for 
     prevention, intervention, and treatment.
       The President's plan, though imaginative and clearly intent 
     on broad and thorough coverage, fails to get over the barrier 
     of fallacious actuarial considerations. The results are penny 
     wise, but pound foolish. The most conservative studies 
     indicate that for every $1 spent for the direct treatment of 
     addiction, society saves nearly $10 in health care costs, 
     crime, accidents, and job performance.\13\
       A government that short-changes substance abuse treatment 
     and prevention is not serious about reducing health care 
     costs.
       A government that short-changes substance abuse treatment 
     and prevention is not serious about reducing crime.
       A government that short-changes substance abuse treatment 
     and prevention loses our best shot at significant and long-
     term economic growth.
       To meet the opportunity I present today, Congress must pass 
     health care reform which recognizes the relationship between 
     addiction treatment and the prevention of later heart 
     disease, liver collapse, accidents, crime, and a host of 
     other tragic and costly outcomes. I offer you today some 
     benchmark provisions that make that distinction. Without 
     these provisions, we fail to connect care with ultimate 
     savings. Without these provisions, we muddle along with band-
     aid cures but not substantial inroads into the 80 percent of 
     our population who generate the costs but will not 
     voluntarily look for a new way of life.
       Here are the specific recommendations to strengthen the 
     substance abuse benefit in the Health Security Act S. 1757/
     H.R. 3600:
       1. Separate the substance abuse benefit from the mental 
     health benefit. These are separate health issues and their 
     treatment--and the cost of that treatment--is distinctly 
     different. Pitting these disciplines against each other for 
     use of benefit provisions is not in the interest of the 
     patient.
       2. Establish standard requirements for treatment, removing 
     stipulations that currently leave plan managers free to 
     determine eligibility. Establish standard eligibility 
     criteria according to current standard diagnosis and 
     functional impairment criteria.
       3. Legislate a minimum benefit for substance abuse 
     treatment that is guaranteed to be available to those who 
     meet eligibility criteria. We recommend such a minimum to be 
     consistent with most current health insurance and managed 
     care health plans, i.e., 10 hours' assessment and 
     intervention services; Detoxification as indicated by acute 
     intoxication and/or withdrawal potential; 30 days' 
     residential or inpatient rehabilitation (45 for adolescents); 
     130 hours outpatient treatment and/or aftercare. If the scope 
     of a national health care plan is to include prevention and 
     long-term care traditionally funded through public sector 
     block grants, we recommend that all limits on benefits be 
     eliminated.
       4. Treatment should be reimbursed on the level of care 
     (i.e., inpatient, acute care, residential, outpatient) rather 
     than on the setting.
       5. Maintain funding for the Substance Abuse Block Grant and 
     other federal programs and require states to maintain their 
     investment in alcohol and other drug treatment. Public and 
     private systems can be successfully integrated only when (1) 
     universal coverage is achieved and (2) quality and outcomes 
     data--not just costs--drive managed care decisions.
       6. Eliminate cost sharing for alcohol and other drug 
     treatment services or establish a sliding fee scale for the 
     cost sharing requirement. Make any and all cost-sharing, co-
     pay, and deductible issues comparable to other diseases. 
     Discriminatory practices to limit access under the argument 
     that savings are achieved cannot be permitted.
       7. Use the same utilization review and pretreatment 
     authorization procedures for all services and replace the 
     arbitrary substance abuse standards to be decided by each 
     health plan with standard criteria, such as the Patient 
     Placement Criteria for psychoactive Substance Abuse Disorders 
     published by the American Society of Addiction Medicine. 
     Without standard criteria, no comparison or study can be 
     valid.
       8. Specify uniform standards for assessment, patient 
     satisfaction, and treatment outcome studies.
       9. Require all substance abuse treatment and case 
     management decisions, including precertification screening 
     and utilization review, to be made by professionals who are 
     licensed or certified in alcohol and other drug treatment.
       10. Designate community-based alcohol and other drug 
     programs as essential providers.
       11. Allow for treatment outside the local health alliance 
     at Centers of Excellence to ensure competition on the basis 
     of quality and cost.
       These are not expensive provisions. The actuarial 
     information being used to suggest cutting addiction disease 
     benefits is based on the potential of all current alcoholics 
     and drug addicts using these benefits this year. We should be 
     so lucky. Sadly, less than 1 percent of those eligible for 
     treatment through insurance or Medicaid actually seek medical 
     help.\14\ If that number rose to even 30 percent, the 
     positive financial impact on America would be tremendous.
       So don't be put off by these misleading projections.
       Act instead for a stigma-free, recovery-oriented society.
       The actions we propose will save billions of dollars. It 
     will make genuine health care cost containment achievable in 
     this century.
       It will also save lives. Millions of lives.
       And it will recover our nation's collective ability to 
     discover and seek the best in our people. We can move beyond 
     survival. We can contemplate renewal. Of individuals. Of 
     communities. Of nations. Of civilizations.
       It is not too much to ask that we do the things which make 
     good business sense and at the same time ensure the greatness 
     of our country.


                                footnotes

     \1\James W. Langenbucher, Barbara S. McCrady, John Brick, and 
     Richard Esterly. ``Socioeconomic Evaluations of Addictions 
     Treatment.'' Piscataway, NJ: Center of Alcohol Studies, 
     Rutgers University 1993. Prepared at the request of the 
     President's Commission on Model State Drug Laws.
     \2\Center on Addiction and Substance Abuse (CASA) and the 
     Brown University Center for Alcohol and Addiction Studies 
     (CAAS). Recommendations on Substance Abuse Coverage and 
     Health Care Reform. New York: Center on Addiction and 
     Substance Abuse at Columbia University 1993.
     \3\Langenbucher, et al., 1993.
     \4\American Medical Association. Factors Contributing to the 
     Health Care Cost Problem. Chicago, IL. American Medical 
     Association 1993.
     \5\Langenbucher, et al., 1993.
     \6\Judy Ann Bigby, William Butynski, et al. Statement to the 
     President's Task Force on National Health Care Reform; 
     Alcohol, Nicotine, and Other Drug Problems. April 2, 1993.
     \7\AMA 1993.
     \8\Bureau of Justice Statistics. ``Survey of Youth in 
     Custody.'' NCJ-113365 1987; and ``1989 Survey of Jail 
     Inmates,'' and ``1986 Survey of State Prison Inmates,'' 
     unpublished analyses.
     \9\U.S. Bureau of Prisons. ``Special Analysis.'' February 1, 
     1994.
     \10\Dorothy P. Rice, Sander Kelman, Leonard S. Miller, and 
     Sarah Dunmeyer. The Economic Costs of Alcohol Abuse and 
     Mental Illness: 1985. Washington, DC: U.S. Government 
     Printing Office 1990.
     \11\Langenbucher, et al., 1993.
     \12\Ibid.
     \13\Ibid.
     \14\Ibid.