Do no harm

Why every candidate campaigning on criminal justice reform needs to be talking about addiction

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Hillary Clinton announced on Wednesday a proposal to address the “quiet epidemic” of heroin and prescription drug use by expanding treatment options and sentencing reform for low-level and non-violent drug offenses.

In an op-ed for the New Hampshire Union Leader, Clinton wrote that her plan prioritizes “treatment over prison,” and outlined a concrete proposal to put federal dollars toward prevention and treatment programs. The plan allocates a total of $10 billion over 10 years—$7.5 billion will be funds to support new federal-state partnerships and $2.5 billion will go to expand existing block grants.

The money talk matters, experts say.

“Those are the numbers that have been missing in a lot of the policy debate so far,” Daniel Raymond, policy director at the Harm Reduction Coalition, told me. “We know that we need to invest more in prevention, treatment, and harm reduction, but so far we’ve been in a budget environment where Congress, at most, has committed to incremental increases that just aren’t sufficient to tackle that scope of the problem.”

In 2013, nearly 23 million Americans needed treatment for substance use, but less than 1 in 10 actually received care at a specialized facility, according to the National Survey on Drug Use and Health.

Clinton’s proposal, by focusing on expanding treatment options and getting specific about the money required to do it, could begin to address this gap, Raymond explained: “A lot of what Clinton’s proposing is consistent with what people in the field say is really needed.”

And part of what’s needed is a robust healthcare system that can ensure people who need treatment receive care. The Affordable Care Act has extended health coverage to 16 million people, but millions of people are still shut out of accessing healthcare. And for those experiencing substance use disorders, jails and prisons have come to serve as a kind of repository for people who need treatment, a point Clinton noted in her op-ed.

“It’s time we recognize that our state and federal prisons, where 65 percent of inmates meet medical criteria for substance use disorders, are no substitute for proper treatment—and reform our criminal justice system,” Clinton wrote.

The Democratic frontrunner isn’t the only candidate making this point. But the question of healthcare—how it’s delivered and what role the government should play in its delivery—is a fracture line in the current bipartisan coalition backing criminal justice reform.

And several Republicans leading the call to reform sentencing and revise how the system treats low-level drug offenses—most notably Sen. Mike Lee of Utah—are, at the same time, pushing to repeal the new healthcare law.

Rand Paul—who has also made criminal justice reform a major issue this campaign and, like Clinton, supports an expansion of medication-assisted treatment as an alternative to incarcerationjoined a majority of those running in the GOP primary to denounce a June Supreme Court decision upholding the law and push for repeal.

“I would make it my mission to repeal it, and propose real solutions for our healthcare system,” Paul said in a statement. “As a physician, I know Americans need a healthcare system that reconnects patients, families, and doctors, rather than growing government bureaucracy.”

“None of the proposals add up in terms of ensuring that we have expanded care,” Raymond said of Republican opposition to Obamacare. “If you’re talking about block granting Medicaid [requiring states to rely on a fixed sum to administer the program], if you’re talking about removing really critical protections, you’re going to end up with a weaker healthcare infrastructure that won’t be able to deliver the care that’s needed.”

A notable exception, he added, is Ohio Gov. John Kasich, who has defended his decision to expand Medicaid in his state by talking explicitly about the healthcare needs of his constituents.

“Ohio was in the midst of an opioid and heroin crisis, and they needed those tools and resources,” Raymond said.

He called Clinton’s proposal promising, but said there’s still more work to be done when it comes to getting people with substance use disorders the support they need and promoting community health.

“I’m still waiting for a presidential candidate who will use the words ‘harm reduction.’ A lot of these proposals are consistent with harm reduction principles, but we’re seeing, at the state and local level, harm reduction strategies like overdose prevention and syringe exchange become much more mainstream,” Raymond explained. “I would hope that other candidates, both Democrat and Republican, start to really flesh that out and acknowledge that we need a much bigger investment if we’re going to get our hands around the opioid and heroin crisis.”