Harm reduction means fighting for health care
The opioid and heroin crisis has dominated my work and that of many of my colleagues — many of you — for the past several years. We’ve fought together for broader access to naloxone for people who use drugs, their loved ones, and other bystanders, to save the lives of people at risk of overdose deaths. We’ve led the charge to expand syringe access and harm reduction programs to parts of the country that never had them before, and remove barriers to federal funding. We’ve pushed to remove limits to buprenorphine to treat opioid use disorders, advocated for hepatitis C treatment for people who use drugs, argued against criminalizing opioid-dependent pregnant women, and called for emphasizing public health strategies over traditional law enforcement approaches. We’ve shifted public discourse and policy towards harm reduction goals and interventions, even to the point of meaningfully debating supervised injection facilities for the first time in the United States.
We’ve been winning major battles, but we continue to lose the war — overdose deaths and new hepatitis C infections are still rising faster than we can scale up harm reduction programs. Moreover, we confront a stark reality: we can’t end the overdose epidemic without harm reduction, but harm reduction alone is not sufficient. In the midst of this crisis, our best hope for protecting the health and lives of people who use drugs is to link harm reduction to access to quality health care.
Without access to health care, people won’t get buprenorphine, or hepatitis C treatment, or hepatitis B vaccination, or all the other kinds of care that we know can protect and improve drug user health. This is what’s at stake in the political fight over repealing and replacing the Affordable Care Act: who deserves health care? Who lives and who dies?
The Trump Administration and Republican Congressional leadership have made their answers clear: to them, health care is a privilege, not a right. They’re willing to make health care coverage out of reach for over 20 million Americans. People with lower incomes would be paying more for health insurance that covers less. They’d not only roll back Medicaid expansion, but end Medicaid as we know it — shifting the burden of costs to cash-strapped states, gutting its status as an entitlement program, and cutting hundreds of billions of dollars in federal funding to finance a tax cut for the ultra-wealthy. They want to remove regulations and protections that have improved the affordability, quality and comprehensiveness of health care for the poor and the sick. They want to turn back the clock to a time when insurers did not have to cover substance use or mental health care.
This is much bigger than the on-going debate about the merits of the Affordable Care Act. The Republican “replacement” bill — the American Health Care Act — represents the first step in a sweeping attack on the safety net, a rupture in the social contract which for decades has found consensus in the principle that our nation has a responsibility for the health and welfare of its most vulnerable members. As a candidate, Donald Trump called for greater access to drug treatment, and promised that he wouldn’t let people die in the streets for lack of health care. As president, he has led the charge for a bill that would do exactly that — and people who use drugs have the most to lose from the Republican health care bill.
The fight for harm reduction takes many forms, but it must always be a fight for health care. People who use drugs have historically not fared well under our fragmented health care system, contending with barriers and stigma. We still struggle with restrictions on hepatitis C treatment, infrastructure and capacity for evidence-based treatment of opioid use disorders, and establishing models of non-judgmental, non-coercive care that meet people who use drugs where they’re at — not just as patients, but as partners in their own health. We cannot afford to lose critical protections of the Affordable Care Act that give us better tools and incentives to raise the bar for quality health care for people who use drugs.
Harm reduction needs more from health care, not less — we need insurers and Medicaid paying for naloxone and medication-assisted treatment, and covering wrap-around services and outreach at harm reduction programs. We need reimbursable on-site health care at our syringe access programs, and a health care system incentivized to provide appropriate, comprehensive health care to people who use drugs, instead of pushing them out the door. These are real, concrete possibilities that we can work towards. Our current system is far from perfect, but it’s the best foundation we’ve ever had to build on. The American Health Care Act would demolish all of that.
Moreover, a robust harm reduction-health care alliance is our best line of defense against a backlash that threatens to restore criminal justice to the center of drug policy. The opioid and heroin crisis have elevated the role of harm reduction, public health, and health care as solutions, under the mantra that “we can’t arrest our way out of this epidemic.” But there are forces — including our new Attorney General, Jeff Sessions — eager to turn back the clock to an ‘80s-style War on Drugs, complete with more prosecutions and more punishment. Sessions has cast doubt on the value and effectiveness of drug treatment; the erosion of coverage, access, and reimbursement for drug treatment that the American Health Care Act would unleash will be used to justify doubling down on arrests and coercion.
When we fight for harm reduction, we go after the biggest risks and threats to people who use drugs. The American Health Care Act poses a clear and present danger to drug user health. In the midst of an unprecedented overdose crisis, we cannot afford to be silent on what the stakes truly are for our communities: a matter of life and death.
I am furious that we’re having this fight, and fearful of what it portends. Get angry and get active: call your Representative now.
