6 things to expect from Biden on SUD treatment
Joe Biden is entering office with nearly the entirety of the republican establishment pretending his win was illegitimate. These arguments didn’t fair well in court, and it is certain that Biden will be inaugurated as the next president of the US. His administration, and his ability to drive policies around SUD treatment, comes down to how the Senate runoff races play out in Georgia and if democrats toss the filibuster. Even if the democrats win both races and take the senate, if they don’t get rid of the filibuster, little will be accomplished. Senator Mitch McConnell’s universal use of the filibuster ensures that nearly nothing will be accomplished without his go-ahead or a supermajority.
So, the uncertainty with the Biden administration re: SUD services is not really one of policy — we know where he stands. It is one of political calculation and whether or not he will get buy-in from republicans or the conservative wing of the democratic party. If they keep the filibuster, bridging the partisan chasm will be the challenge. If they toss it? Conservative democrats will be able to drive policy through hostage negotiation.
Biden has advocated for increasing funding for prevention, treatment and recovery supports during his run for president, and vows to increase funding by $125 billion to address the opioid crisis. He has apologized for his support of the drug bills he championed in the 80s and 90s which drove massive sentencing disparities and mass incarceration. His widely publicized correspondence with his son — Hunter Biden — while he was in treatment for substance use shows an empathetic father connected to these issues on a personal level. So, if DC weren’t the setting of sort of mescaline-fueled Game of Thrones/House of Cards mashup, things would be looking great for people who want to see improvements in our system of care…
Here is our list of what could happen:
Federal decriminalization of marijuana
Biden has taken lumps for resisting those in his own party who want to move toward full legalization of cannabis, and he has always seemed hesitant to fully embrace this position. The only thing that had a good election cycle in 2020 across the board was drugs. The bipartisan support for legalization may force Biden and Senate republicans to work together, or more likely, it will embolden the conservatives in the democratic party to buck Schumer, Biden and Pelosi if they advance what is perceived as too ambitious of an agenda.
2. A return to partisan, deficit-focused fighting
Republicans have been mostly on board with increased SUD treatment since the passage of parity. For decades, increased spending related to treatment and support for SUD reforms has been largely outside of the typical partisan battles. More recently, Republicans have shown that they are not monolithic on this issue and support is not guaranteed. I believe we will see a return to the deficit-focused arguments that have historically been aimed at increases in entitlements, especially if Biden attempts to increase Medicaid eligibility and expand the Affordable Care Act, like he has promised.
3. Governors rule
As parity remains largely unenforced and the expansion of Medicaid has driven access to treatment for SUD across the country, Governors will make or break our response to our national addiction crisis. Their Attorneys General can set the tone for parity. The federal government will continue to be a mess of partisanship and obstruction. There is no reason to expect an appeal to our better angels will change that, although it is possible that some of the more wonkish pieces of policy and spending aren’t subject to republican obstruction. Regardless, the opportunity here is for active governors to implement progressive policies related to prevention, recovery and treatment.
4. Reform vs. Rebuild
Biden positioned his campaign in the democratic primary as an alternative to the revolutionary approach to government associated with Bernie Sanders and the Justice Democrats. He ended the campaign by appealing to disaffected republicans, aligning himself more with people like John Kasich and the Lincoln Project founders than the more liberal wing of his party. I don’t see him nominating somebody like AOC, Senator Warren or Sanders himself to prominent positions in his administration. It goes against everything he and Obama fought for, and guarantees that the pending civil war within the larger party becomes a knife-fight within the administration. His administration’s work on SUD treatment — which will intersect with the demand for criminal justice reform, how the Biden DOJ and DEA will align (or not) with his reform initiatives, and the larger conversation around racial equity — will likely become a front in the war between experienced leaders from the consulting, academic and bureaucratic worlds and advocates who are frustrated with the lack of vision and no tolerance for timidity.
5. Sneaky wins
While Biden attempts to reassemble the parts of government that were torched under the Trump administration, all eyes will be on the spectacle of what is uncovered. The potential prosecution of Trump for state — and potentially federal — crimes will continue to take up the news cycle. There is substantial opportunity for nonconformists from both parties to affect change. I would not be surprised to see bizarre dance partners collide to support SUD legislation. Think of how an AOC/Markwayne Mullins collaboration might look in the house? Anything is possible.
6. Continued failure
Biden has appeared unable or unwilling to address the foundational problems that plague the healthcare system. Like most centrist democrats and all republicans, there is absolutely no willingness to look to the insurance industry for reform. There may be some picking around the edges — increasing access to Medicaid or attempting to repeal the inmate exclusion — but wholesale changes are off the table. His administration will likely be filled with people who see these institutions as an inevitability and treat them like other large-scale donors — with fear and deference. Improvement is possible, but the foundational problem of profit-motive driving healthcare, incarceration, and support for the status quo around the racial and financial inequities perpetuated by these systems will remain largely unaddressed.