Hillary Clinton has one of the most progressive anti-drug plans in decades

Each year, tens of thousands Americans die due to problems related to drug and alcohol abuse. Hillary Clinton has a plan to change that — not by escalating the war on drugs, but by rolling it back and directing funds away from mass incarceration and toward treating addiction as a serious medical and public health challenge.

Clinton’s $10 billion Initiative to Combat America’s Deadly Epidemic of Drug and Alcohol Addiction is the most ambitious attempt of any presidential candidate to tackle America’s struggles with drug abuse. It’s an approach that public health and drug policy experts have demanded for years. But Clinton is the first candidate to dedicate such a large sum of money to the cause — and if approved by Congress, it could help combat what some public health officials and experts have called a drug overdose epidemic.

The big idea behind Clinton’s plan is to shift public policy on drug abuse and addiction from the criminal justice system to the health-care system. It would also help fill a big gap in health care: Nearly 90 percent of people who have a drug or alcohol abuse problem don’t get treatment, according to federal data.

“Plain and simple, drug and alcohol addiction is a disease, not a moral failing — and we must treat it as such,” Clinton wrote in an op-ed for the New Hampshire Union Leader. “It’s time we recognize that there are gaps in our health-care system that allow too many to go without care — and invest in treatment. 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.”

The plan would establish $7.5 billion in federal funds to encourage states to set up their own plans to fight drug abuse and addiction. States would have to show how they will work with local governments and other stakeholders, according to Clinton. For every $1 they commit to their plans, they can receive up to $4 in federal funds.

Clinton outlines several ways states could receive these federal funds:

On a federal level, Clinton’s plan would offer several other initiatives:

Keith Humphreys, a drug policy expert at Stanford University, said the most promising part of Clinton’s plan is how large it is — with an annual price tag of $1 billion. Humphreys compared it with other programs, such as the $2.5 million the White House set out to fight heroin abuse and the additional $133 million the Department of Health and Human Services proposed to fighting opioid abuse earlier this year. “So just the fact it has the b-word — billion — says to me that Clinton grasps the depth of the problem,” Humphreys said. “This is not a small problem, and it’s not going to go away.”

The most promising proposal in Clinton’s plan, Humphreys said, may be increased enforcement of existing laws and regulations that require insurers to pay for drug abuse treatments. In health care, roughly half of spending comes from private, not public, sources. But it’s likely that many private health plans currently refuse to pay for drug abuse treatments even when it’s required by law.

Humphreys cited New York, where the state attorney has forced insurers into big payouts after they were caught for pretty egregious violations.

“That particular state office got interested in it. California is interested in it. But most of the states aren’t,” Humphreys said. “So there’s other noncompliance going on across the country. And the federal government can do that way better than states can — they have the resources to do it, and they can get a national covenant agreement rather than state by state.”

Still, the plan suffers from one big flaw: It requires a lot of state cooperation.

Although the $7.5 billion will provide a strong financial incentive for a lot of states, there have been cases in the past — such as the Medicaid expansion — in which state governments have refused money out of political and ideological objections. It’s possible that some states, already skeptical of more federal intervention in their politics and policies, will refuse the federal funds and not act at all.

But the states that do participate will greatly benefit. And they’ll help address one of the biggest public health crises of the past few years: a sharp rise in heroin and opioid painkiller abuse.

Since the late 1990s, the number of people dying from opioid painkiller overdoses has steadily risen — with more than 16,000 deaths reported in 2013. What’s worse, one study in JAMA Psychiatry found opioid painkiller use has contributed to the rising use of heroin, which is deadlier and more addictive than painkillers. (A 2015 CDC analysis, for example, found people who are addicted to prescription painkillers are 40 times more likely to be addicted to heroin.)

But these concerning numbers come into conflict with another medical issue: About 100 million US adults suffer from chronic pain, according to a 2011 report from the Institute of Medicine. And although there’s no good evidence that opioid painkillers can treat chronic pain, they can help with acute pain and are commonly prescribed for long-term issues.

Clinton’s plan could prevent many of these opioid overdose deaths through increased funding for prevention and treatment programs. As states experiment with different treatment approaches, they also could pass on the lessons to other states — and save more lives as a result.

But perhaps the most direct effect on deaths could be increased access to naloxone, which reverses the effects of an opioid overdose with no significant side effects. For example, if states use the funds to equip police with naloxone, cops could apply the drug quickly — before paramedics can arrive at the scene — and save someone’s life.

Parts of Clinton’s plan could also prevent opioid abuse altogether by giving doctors better training and tools to know which patients actually need painkillers and which may be likely to abuse them. The federal government has already gone after many lenient prescribers — known as “pill mills” — and Clinton continues that approach. But the crackdown on pill mills has led to a big downside: If painkillers become too difficult to obtain, addicts turn to heroin — a cheaper and more accessible, but more dangerous and illegal, opioid — to satisfy their cravings. If doctors can be trained and given the tools and encouragement to not prescribe so many opioids in the first place, then people won’t get addicted, and they won’t end up seeking heroin when their other opioids are cut off.

Clinton’s plan isn’t limited to opioid abuse. It also hopes to address other forms of drug abuse, including alcohol.

Nearly 44,000 people died from drug overdoses in 2013, and about 88,000 die each year from alcohol-caused problems like liver disease and car crashes, according to the Centers for Disease Control and Prevention. In comparison, there were more than 33,000 firearm deaths in 2013, and nearly 34,000 car crash deaths. And more than 41,000 Americans died from AIDS at the height of the HIV/AIDS epidemic in 1995.

Some of the drug and alcohol deaths occur from casual use — someone may drink for the first time in months, decide to drive, and get in a fatal car crash.

But excessive drug use is a cause in many cases. Years of drinking is much more likely to lead to liver damage. Extended cocaine abuse can similarly heighten the risk of heart disease. Long-term heroin users are at greater risk for an overdose — they use more to meet their greater tolerance for the high, but they don’t develop as strong of a tolerance for the respiratory effects that lead to an overdose. And so on. It’s these types of deaths that Clinton’s plan could help prevent by getting people off drugs.

While Clinton’s plan is expansive, it doesn’t (and probably couldn’t) explicitly mention every idea drug policy experts have been calling for as the country winds down the war on drugs and shifts to other, more health-oriented ways to fight drug abuse.

Here are several big ideas drug policy experts have proposed over the years:

The plan also doesn’t appear to address the deadliest drug in the US: tobacco, which when smoked kills 480,000 people each year, according to the CDC. There are various ideas to deal with this problem, including education campaigns, mandatory warning labels, public and workplace smoking bans, higher taxes on tobacco products, and increasing the smoking age. (Although, traditionally, these anti-tobacco policies aren’t lumped in with anti-drug plans.)

Clinton’s plan could cover some of these ideas if states are allowed to leverage federal funding in creative ways not outlined in the plan. But none of these other proposals appear to be an explicit focus — and some, like the alcohol tax and state monopolies on alcohol sales, will very likely require entirely different legislation.

Still, the plan is more than other presidential candidates and past administrations have called for. At the very least, it’s a big start.