President’s Letter: What the Opioid Crisis Says About Our Health System

Almost every day, we see news stories about the heartbreaking toll of the opioid crisis. We read in detail about the extent of the problem as well as its root causes, including the unscrupulous actions of some members of the pharmaceutical industry. And increasingly, we hear how the ripple effects are reaching children and families—with destructive results (see cover story).

The medical community continues to debate the best treatment approaches, and each of us views the scourge of opioids through our own lens. From where I sit, the crisis lays bare fundamental flaws in our health care system that make quickly and adequately addressing it extremely difficult—even when everyone sincerely wants to. Importantly, these flaws should also serve as a warning sign for future health crises. Five problems stand out:


Our health care system is almost entirely built around treating diseases rather than preventing illnesses. We perform near-miraculous medical interventions for complex diseases and injuries and often get paid handsomely to do so. But we are almost never paid for successfully preventing an illness. When it comes to the opioid crisis, prevention efforts are often not reimbursed at all from health care dollars and require the allocation of external funds (though in this case, inadequate access and reimbursement for substance use treatment are also serious problems). The short shrift accorded to prevention is also a problem for many other diseases afflicting our nation—from diabetes and heart disease to lung cancer. We will not be able to create a healthier United States without striking a better balance between prevention and treatment.


Although the opioid epidemic has affected almost all demographic groups, economically disadvantaged populations have been particularly hard hit. For these patients, the Medicaid program is critical to accessing treatment—yet 14 states have still not adopted Medicaid expansion as part of the Affordable Care Act (ACA). Even in New York State, where we have aggressively utilized all the tools available from the ACA, over 1 million remain uninsured. Leaving significant portions of our population without coverage is not only unconscionable—it will prevent us from adequately addressing the opioid epidemic and future health crises.


Behavioral health (including substance use disorders) and physical health are frequently intertwined, yet they are often addressed separately within provider, regulatory, and payment systems. Patients, of course, do not have the luxury of compartmentalizing their health issues. To deliver effective care, we need to focus not on this or that disorder but on the well-being of the whole person. That said, silos within the health system are only part of the problem. To sufficiently address many crises, health care needs to better coordinate with other sectors. In the case of opioids, that means, for instance, building bridges with criminal justice, child welfare, education, and emergency management.


It’s clear that the opioid crisis is not purely a medical issue and is inextricably linked to larger socioeconomic factors like poverty and unemployment—so-called “social determinants of health.” In fact, these determinants are not limited to opioids but have an outsized impact on well-being across numerous conditions, leading to profound disparities between advantaged and disadvantaged populations. Our health system cannot achieve better outcomes without addressing and responding to broader health determinants.


The opioid crisis has highlighted deficiencies in the behavioral health workforce. But this is just one of many health care workforce challenges that we will face in the future, including chronic shortages among primary care physicians and non-physician clinicians, such as home health workers. This will only be exacerbated as the U.S. population ages—the number of Americans over 65 will double in four decades. How we manage the workforce pipeline will be a critical question over the next several years.


The opioid crisis yields numerous additional challenges, some of which are more specific to substance use disorders. But the issues outlined above are linked to many other health crises that we currently face or will likely face in the future. Until we tackle these fundamental challenges head on, attaining optimal health for everyone will remain elusive.


Reprinted from Blueprint, Fall/Winter 2018.