Three decades ago, Nancy Reagan launched her famous anti-drug campaign when she told American citizens, “Say yes to your life. And when it comes to alcohol and drugs, just say no.” ¹ Last month, Attorney General Jeff Sessions invoked the former First Lady’s legacy in a speech to Virginia law enforcement when he said, “ I think we have too much tolerance for drug use– psychologically, politically, morally. We need to say, as Nancy Reagan said, ‘Just say no.’”² As our nation is confronted on a daily basis with the tragic effects of the opioid epidemic, it is important that we understand just how dangerous it is to suggest that we return to the ‘just say no’ approach.

In the 1980s and 1990s, the ‘just say no’ curriculum became the dominant drug education program nationwide in the form of DARE.³ The DARE program– Drug Abuse Resistance Education– was developed in 1983 by the Los Angeles police chief in collaboration with a physician, Dr. Ruth Rich. The pair adapted a drug education curriculum that was in the development process at University of Southern California in order to create a program that would be taught by police officers and would teach students to resist the peer pressure to use alcohol and drugs. With the backdrop of the War on Drugs that had continued from the Nixon presidency into the Reagan era, DARE grew quickly. Communities understandably wanted to prevent their children from using alcohol and drugs. The program was soon being used in 75% of schools nationwide and had a multimillion dollar budget.³ In fact, I would bet that many of you reading this are DARE graduates. I certainly am.

It did not take long for there to be research showing that the ‘just say no’ approach used in DARE was not working. By the early 1990s there were multiple studies showing that DARE had no effect on its graduates choices regarding alcohol and drug use.⁴ The decision to ignore the research about DARE culminated when the National Institute of Justice evaluated the program in 1994, concluded that it was ineffective, and proceeded to not publish this finding. In the 10 years that followed, DARE was subjected to evaluation by the Department of Education, the U.S Surgeon General’s Office, and the Government Accountability Office.⁴ The combined effect of these evaluations was the eventual transformation of DARE into an evidence-based curriculum, Keepin’ It REAL, which was released in 2011.⁵ But this only happened after billions of dollars were spent on a program that did not work and millions of students received inadequate drug education.

And yet, here we are again. The top law enforcement officer in our nation is suggesting that we go back to the days where elementary and middle school students were told that all they needed to do was ‘just say no.’

The current opioid epidemic is resulting in a staggering number of deaths. As of the end of 2016, an estimated 91 people were dying from an opioid-related overdose daily.⁶ Here in Massachusetts, the numbers seem to only be getting worse as more people are unintentionally overdosing on fentanyl.⁷ According to state data, fentanyl was involved in 75% of overdoses in 2016.⁷

We know that drug use in adolescence is a major risk factor for addiction, and therefore, overdose. For adolescents who use illegal drugs before age 13, over two-thirds suffer from a substance use disorder within 7 years of their first use.⁸ This figure drops to under one third when the age of first use is over 17.⁸ We also know that teaching adolescents a curriculum based on ‘just say no’ does not work.

A few days ago, I had the chance to visit AHOPE, the Boston needle and syringe exchange program. Upon walking into the needle exchange, I was struck by the pictures of smiling faces and printed obituaries that plaster the walls, memorializing the many people who have recently lost their lives to overdose. Almost all of these faces are young.

Stopping the overdose epidemic in the United States is going to require a massive effort at all different levels. Prevention of substance use disorders is one part of this effort, and educational programs for children and adolescents is a key component of prevention. It is hard to think about how many of the people we have lost to substance use disorder completed DARE or other ‘just say no’ programs. We need to look at the evidence and not allow ourselves to repeat history. We can do better, and Attorney General Sessions should create policies that will help us do better.

1. Shen, A. “The Disastrous Legacy of Nancy Reagan’s Just Say No Campaign.” ThinkProgress. 6 March 2016.  https://thinkprogress.org/the-disastrous-legacy-of-nancy-reagans-just-say-no-campaign-fd24570bf109. Accessed 7 April 2017.
2. Schuppe, John. “Just Say No: AG Sessions Cites Old School Anti Drug Motto.” NBC News. 16 March 2017. http://www.nbcnews.com/news/us-news/just-say-no-ag-sessions-cites-old-school-anti-drug-n733961. Accessed 7 April 2017.
3. Cima, Rosie. “DARE: The anti-drug program that never actually worked.” Priceonomics. 19 Dec. 2016. https://priceonomics.com/dare-the-anti-drug-program-that-never-actually/. Accessed 7 April 2017.
4. Arkowitz, Hal and Lilienfield, Scott. “Why ‘Just Say No’ Doesn’t Work.” Scientific American. 1 Jan. 2014. https://www.scientificamerican.com/article/why-just-say-no-doesnt-work/. Accessed 7 April 2017.
5. Nordrum, Amy. “The New D.A.R.E. Program– This one works.” Scientific American. 10 Sep. 2014. https://www.scientificamerican.com/article/the-new-d-a-r-e-program-this-one-works/. Accessed 7 April 2017.
6. CDC. “Understanding the Epidemic.” CDC: Opioid Overdose. 16 Dec. 2016. https://www.cdc.gov/drugoverdose/epidemic/. Accessed 7 April 2017.
7. Bebinger, Martha. “Fentanyl Adds a New Terror for People Abusing Opioids.” NPR Shots. 6 April 2017. http://www.npr.org/sections/health-shots/2017/04/06/521248448/fentanyl-adds-a-new-terror-for-people-abusing-opioids. Accessed 7 April 2017.
8. U.S. Department of Health and Human Services (HHS). Office of the Surgeon General, Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs, and Health. Washington, DC: HHS, Nov. 2016. https://addiction.surgeongeneral.gov/executive-summary.pdf. Accessed 7 April 2017.

While it seems there is little on which politicians can agree when it comes to health care, one thing they seem to agree on is that our current system leaves many Americans without affordable access to healthcare. It is time for a major change in how Americans acquire health insurance. It is time that we separate health insurance from employment.

The marriage between employment and health insurance started in the 1920’s—a time when medical practice was advancing rapidly and so was the cost of health care. Baylor hospital in Dallas, Texas noticed that most working class people could not pay for the cost of a hospitalization but they could afford luxury items like cosmetics when they were purchased a little at a time. Baylor started a program with the local public school teachers where, for 50 cents per month, Baylor would cover the cost of their hospital visits. This idea grew in popularity and developed into Blue Cross insurance.

The link between employment and health insurance became stronger during World War II when, in an effort to attract more workers during a time of wage controls, factories started offering benefits such as health insurance. This link was further strengthened when the IRS passed a law making employer contributions to health insurance exempt from taxes.

According to the Kaiser Family Foundation, as of 2015, 49% of Americans were covered by employer-sponsored health insurance plans¹. For the remaining population, 36% were covered by public insurance such as Medicare, Medicaid, or the Veterans Administration, 7% purchased plans in the non-group market, and 9% of the population remained uninsured.

One of the provisions of the Affordable Care Act, ACA, requires employers with over 50 fulltime employees to offer employer sponsored health insurance to their fulltime employees or be subject to fines. The employer mandate might make sense in the current system where most working Americans receive health insurance through their employer, but the current system leaves those without employer-sponsored health insurance to fend for themselves in the individual market. This arbitrary partnership between employment and health insurance puts a significant burden on small businesses and self-employed individuals.

One of the major criticisms of the ACA is that it is very expensive for businesses with just over 50 employees to offer their employees health insurance. Many of these businesses were faced with the choice of cutting the number of employees or employees’ hours to avoid having to provide health insurance or risk going out of business. But a employer going out of business, moving operations overseas, or cutting hours, benefits neither the employee nor the employer, so why are we putting this pressure on employers?

Additionally, health care is a very personal matter and employers should not have any say in from whom or for what their employees seek healthcare. There have been instances where employers have refused to offer plans that cover certain healthcare services. For example, Hobby Lobby argued that it should not be required to pay for insurance that offered certain types of birth control for their employees because it violated the company’s owners’ religious beliefs. The 10^th Circuit Court of Appeals, including recently confirmed Supreme Court Justice Neil Gorsuch, and later the US Supreme Court upheld the rights of closely held for-profit companies to refuse to offer insurance plans that cover services that are in conflict with the owner’s religious beliefs in the 2014 ruling of Burwell v. Hobby Lobby Stores, Inc.².

But what is the alternative? Historically, people who were self employed or who worked for small businesses that didn’t offer health insurance could purchase their own coverage directly from insurance companies. This process was made easier by the creation of state-run health insurance exchanges under the ACA. Now individuals can purchase health insurance for themselves or their families on the exchanges. Additionally, the ACA provides income-based subsidies for people with lower incomes to make purchasing an insurance plan on the exchanges more affordable.

Some argue that by buying health insurance through their employer, people have greater bargaining power. They argue that entering the health insurance marketplace as an individual gives you less bargaining power, but people enter into individual markets for most other things they buy, including car and homeowners insurance. Having more people purchasing insurance through the individual marketplace would create more competition in the individual market and incentivize insurance companies to create more affordable plans with coverage that meets consumers’ needs. Insurance companies would no longer be negotiating large deals with employers, instead they must appeal directly to consumers and offer plans that meet consumers’ needs.

It is a bizarre relationship for your employer to pick your health insurance provider and by extension, who provides your healthcare. Your employer does not choose where you buy your food, your car, your cell phone, or your home, so why do they choose your health insurance? In a time when people are more mobile in their employment and many small businesses struggle to remain profitable, it is time that we remove employers from the health insurance market and allow all individuals, regardless of their employment status, to purchase their own insurance in the individual market. This is one tiny step that will help make health insurance more accessible to more Americans.

1. Kaiser Family Foundation. (2017). Health Insurance Coverage of the Total Population. Retrieved from http://kff.org/other/state-indicator/total-population/.
2.  Alito, S. (2014). Burwell v. Hobby Lobby Stores, Inc.

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