A cohesive set of national policies is needed, one that recognizes not only that alcoholism is a disease but also that medical solutions alone will not solve social problems.
Across the country, some local solutions are being tried. Housing First, an assistance approach that tries to provide homeless people with permanent housing quickly and gives them supportive services as needed, holds significant promise because it recognizes that the social situation is the real emergency. Housing First would house a person like Mr. P – whose story is told in the accompanying article – without any requirements of sobriety. In cities where it has been studied, the program has been shown to reduce health-care expenses. However, its effectiveness with people like Mr. P, who had been living on the streets for a decade and was struggling with alcoholism, has been questioned.
Diversion programs are another potential solution that treats the social situation first. Under one diversion model, if a person were picked up for public intoxication, he or she would be taken to a sobering center instead of a jail or hospital. Sobering center programs range from mom-and-pop operations in church basements to sophisticated centers with nursing staffs and communications with local emergency dispatch, which coordinates the appropriate response and avoids the situation of sending a firetruck to someone sleeping on a park bench. Some of the programs are run by sheriff’s departments, county health-care agencies or homeless-services organizations. As diverse as the programs are, their missions are similar: to provide a safe place for people to sober up that is not a jail or a hospital. In doing so, they strive to break the cycle of chronic intoxication and provide value-based care at a reduced price.
Additionally, the confusing fog of who pays for the emergency department visits of patients with alcoholism has lifted. In states that expanded eligibility for Medicaid under the Affordable Care Act – including Rhode Island – many of the previously uninsured are now covered by Medicaid. In my hospital, 70 percent of patients who had more than five visits a year for alcohol intoxication had been uninsured. Seventy percent of such patients are now covered by Medicaid, and almost none are uninsured. One morning in early 2014, my patient Mr. P was enrolled in Medicaid with a shaky signature before leaving the hospital.
Whether coverage leads to communities’ embracing innovative programs remains to be seen. However, Medicaid has proved flexible, and many states are using its funding to start alternative diversion programs and sobering centers to address the needs of patients such as Mr. P.
In evolutionary biology, when a new ecological niche opens, diverse organisms attempt to occupy it. It is only after time has passed that the most efficient organism succeeds. While public intoxication is as old as alcohol itself, we are still looking for the best solution, as various local programs across the country attempt to provide it.
There have been estimates of the scope of the problem (almost 10 percent of all ED visits are related to alcohol, according to a 2012 article in the Journal of Studies on Alcohol and Drugs), but there are very few if any robust comparative data about solutions. The science on this topic consists of findings from individual cities and communities with differing laws and politics, leaving providers with the difficult job of identifying generalizable solutions. Moreover, U.S. policies are remnants of the Uniform Alcoholism and Intoxication Treatment Act of 1971 and differ across the country. This is a national problem that has been left to local communities to solve.
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Warren is an attending physician at University Emergency Medicine Foundation in Providence, R.I. This article was excerpted from the November issue of Health Affairs and can be read in its entirety at http://www.healthaffairs.org/.