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.1

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 treating 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." 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.

Notes

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. JudyAnn 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.

For further information, call Johnny W. Allem or Martha E. Rothenberg 202-347-4257 or 1-800-838-SOAR

Chairman STARK. Mr. Gemmell.

STATEMENT OF MICHAEL K. GEMMELL, EXECUTIVE DIRECTOR, ASSOCIATION OF SCHOOLS OF PUBLIC HEALTH Mr. GEMMELL. Good morning, Mr. Chairman. I represent the 26 schools of public health in the United States. The deans appreciate the opportunity to present our views on health reform in general and the training of public health professionals in particular.

Mr. Chairman, public health is the underlying concept of any effective health care reform system. Population-based disease prevention health promotion, which is synonymous with public health, must be the cornerstone of health care reform.

The Association of Schools of Public Health, Mr. Chairman, is on record in support of President Clinton's health care reform bill. We strongly support the public health, preventive medicine and prevention research provisions of the plan, as well as its overall principles of universal coverage, access and cost control.

However, Mr. Chairman, as experts in the public health professions education field, we believe that all health care reform proposals should place more emphasis on relieving the serious shortage of comprehensively trained professionals needed to meet health care reform objectives, especially those trained to deal with previously neglected or unidentified morbidities, such as AIDS, drugs, alcohol, violence, tobacco, and depression, among others.

State and local health department directors have reported that the lack of practical knowledge and skills in the core sciences of public health and preventive medicine have restricted the effectiveness of their agencies. In order to promote the quality of the American public health infrastructure, and therefore to properly set the stage for health care reform, we must provide adequate training, education and continuing education to the public health workforce. We urge Congress to recognize that under health care reform the public health system would be responsible for community assessment of needed services, assurances that groups of providers are available to meet community needs, and for the administration of programs which promote health and prevent disease.

Accordingly, we recommend the following provisions to health care reform: One, recognition of the critical mass of the basic public health sciences of epidemiology and biostatistics, among others, are needed to build the prevention research capacity to rebuild the current public health infrastructure as well as to manage health care reform plans.

Two, that 3 percent of the national health care expenditures should be set aside to support the core functions of public health. We believe it is crucial to provide for a guaranteed, predictable and consistent source of funds for these functions that were identified by the Public Health Service.

And three, consolidation of current Federal academic public programs into a new entitlement that would create a Public Health Services Corps, with individuals with special skills and competency needed to function in a health care reform context.

One final recommendation, Mr. Chairman. We respectfully urge that the medical specialty of preventive medicine be included in a definition of primary care. These physicians play important roles in

many health care settings where expertise in both clinical medicine and the population-based approach of public health is required.

We urge the committee to continue the precedent it set in OBRA 1993, by treating preventive medicine the same as primary care specialties for the purposes of graduate medical education.

Thank you, Mr. Chairman, and members of the committee and subcommittee, for the opportunity to testify on the need for health care reform in general and for the opportunity to present our views on the need for professionals with population-based expertise to accomplish its goals in particular.

Thank you, Mr. Chairman.

Chairman STARK. Thank you.

[The prepared statement and attachment follow:]