Deaths of Despair: Opioid Abuse Devastates America. There Is a Solution

Low-income poorly educated whites between the ages of 45-54 are dying too soon. Unlike every other age, ethnic and racial, education, and income group, this group’s longevity is decreasing. Why? Opioid abuse.

That’s right, prescription painkillers, heroin, Fentanyl, and other opiate derivatives killed more than 33,000 Americans in 2015. That’s about four times the number of opioid-related drug overdose deaths than in 1999.

Nearly half of those overdoses come from prescription painkillers. But the number of prescriptions written for opioids has been on the decline since 2011. That may explain the rise of heroin and Fentanyl, as substitutes for legal opioids. But the turn toward heroin and Fentanyl now exceeds painkillers for the number of deaths each year.

These drugs are extremely potent. Fentanyl, which was created to relieve pain in end-of-life cases, is about 50 times more potent than heroin, but people can survive it because they build up a tolerance.

The related costs associated with this national epidemic total about $77 billion.

That seems shockingly high, but consider some of the tentacles of the epidemic. The foster care system is overwhelmed. West Virginia, which has the highest overdose death rate in America, has run out of funding for funeral burial benefits. Ohio has started building portable morgues because coroners’ offices are full. The state of Arizona recently concluded that on average, more than two Arizonans die every day in 2016 due to opioid-related overdoses.

To put it bluntly, the United States has a killer problem on its hands.

Christopher Caldwell, a senior editor at The Weekly Standard and author of an essay entitled, “American Carnage: The New Landscape of Opioid Addiction,” recently spoke at a conference about the massive growth in opioid-related deaths. It’s a problem that began long ago.

The specific problem of opioids, I think, has to do with the confluence of three things in the 19th century: In the start of the 19th century, scientists were able to isolate morphine, the chemical in opium poppies. In the 1850s, we invented the hypodermic needle, and in the 1860s, we fought the bloodiest war in the history of the planet, and a lot of people came home with what we now call chronic pain, and the ability of, the uses of this drug were just infinite.

It was over-prescribed. You know what happened, or you can predict what happened. A lot of mothers and teachers, and like, pillars of the community, got addicted and died.

It wasn’t until soon before the first World War that the first drug laws were passed. Drugs became taboo, but after Vietnam, drug use started rising again, and with that, so did drug deaths. The use of crack in the 1980s began elevating the death rate. But the spike in recent years is a whole different animal.

So can something be done? Well, resources seem to be moving in the right direction, and in one of those rare good news stories, federal money is being directed toward actual solutions.

For instance, drug courts have expanded access to medication-assisted treatment (like methadone), and residential treatment programs, as opposed to jail, are helping addicts recover, not languish in prisons.

Harold Pollack, a professor in the School of Social Service Administration at the University of Chicago and a contributing researcher to the National Drug Abuse Treatment Systems Survey, which tracks drug addiction and substance abuse treatment programs nationwide, says there is also some movement among lawmakers “who are looking at a map of the nation, and seeing the problem is everywhere.”

“Antiquated behavioral health systems” are being given new life with federal funding. Ironically, the source of these solutions are being funded in part by one of the most controversial assistance programs out there – Medicaid.

“Medicaid is kind of the ball game on the service side. It’s so much more important than the (21st Century) Cures Act or anything else that people are going to talk about,” Pollack said.

Pollack said that as lawmakers figure out how to replace the Affordable Care Act, one of the issues that isn’t on the chopping block is mental health parity in health care, which includes addressing the symptoms that lead to drug addiction.

What’s striking is ACA-Medicaid expansion is kind of the quiet model for successful bipartisan health policy. Nobody really wants to talk about it, but that’s what is happening on the ground. When you call up someone in a random state … the conversation is about the work, it’s not about the politics.

And in fact, when we ask people you know there’s just been an election, does that change anything, the most common answer we here is, ‘We’ve been told from our governor just do the work, don’t pay attention to what’s happening in Washington, just keep doing. And I actually find that very encouraging. Democrats and Republicans around the country are governing and they’re really trying hard to deal with this because they see this map, and they don’t want people to die.

Pollack notes that Medicaid expansion has been good and bad, and when it comes to addressing the drug crisis, and policymakers “know less than we should about what’s happening out there.” Fortunately, he said, the problem is finally being taken seriously, though it’s unfortunate the conditions that had to arise before it did.

The crack epidemic, the HIV  work, when the drug problem was much more black and brown in its public conception than it is now, that’s a welcome change. I must say I feel a certain sense of sadness at seeing the difference in public reaction but it’s a good thing that people are responding with empathy and compassion.

Watch more about the opioid epidemic.

Suffering in ‘Real America’: The 21st Century Experience

Turns out America’s elite — the “talking and deciding classes,” as demographer Nick Eberstadt calls it — didn’t realize until Donald Trump was elected president that things weren’t going as swimmingly for Americans in the heartland as for Americans in the “bubble.”

The wake-up call, however, has been in the making for more than 15 years. “Real America” has been suffering through most of the 21st century, and the start of the difficulties can be traced to “a grim historical milestone of sorts.”

Eberstadt, who studies poverty trends, economic development, and political economy, says that the year 2000 is when the “Great American Escalator, which had lifted successive generations of Americans to ever higher standards of living and levels of social well-being, broke down around then — and broke down very badly.”

Since 2000, America has been experiencing “an ominous and growing divergence between three trends that should ordinarily move in tandem: wealth, output, and employment. Depending upon which of these three indicators you choose, America looks to be heading up, down, or more or less nowhere.”

In terms of wealth, things look good. The estimated net worth of American households and nonprofit institutions more than doubled between early 2000 and late 2016, from $44 trillion to $90 trillion.

Although that wealth is not evenly distributed, it is still a fantastic sum of money—an average of over a million dollars for every notional family of four. This upsurge of wealth took place despite the crash of 2008 — indeed, private wealth holdings are over $20 trillion higher now than they were at their pre-crash apogee. The value of American real-estate assets is near or at all-time highs, and America’s businesses appear to be thriving. Even before the “Trump rally” of late 2016 and early 2017, U.S. equities markets were hitting new highs — and since stock prices are strongly shaped by expectations of future profits, investors evidently are counting on the continuation of the current happy days for U.S. asset holders for some time to come.

That’s the good news. But looking at the economy from a different lens casts quite a stormy picture. The economic crash of 2008 was pretty awful, granted, but the recovery has been super slow, with the total value of the U.S. economy in 2016 being just 12 percent higher than it was in 2007.  However, the slowdown didn’t start in 2008.

Between late 2000 and late 2007, per capita GDP growth averaged less than 1.5 percent per annum. That compares with the nation’s long-term postwar 1948–2000 per capita growth rate of almost 2.3 percent, which in turn can be compared to the ‘snap back” tempo of 1.1 percent per annum since per capita GDP bottomed out in 2009. Between 2000 and 2016, per capita growth in America has averaged less than 1 percent a year. To state it plainly: With postwar, pre-21st-century rates for the years 20002016, per capita GDP in America would be more than 20 percent higher than it is today.

What is the cause of this middling performance? Economists can’t agree … except on one thing: The U.S. economy’s potential is declining — meaning that Americans should not expect growth to exceed 1 percent per year if things stay as they are.

Thirdly, Eberstadt notes that the jobs situation is shockingly pathetic. The labor force participation rate — the measure of what percentage of Americans age 20 and older are working — took a huge dive in 2007, and hasn’t come back up yet to where it was.

But again, it didn’t start there. U.S. adult work rates never recovered entirely from the recession of 2001, Eberstadt writes, even as America’s elite cite the oft-quoted “civilian unemployment rate,” to claim a rosy picture. In December 2016 the unemployment rate stood at 4.7 percent, about the same as in 1965, at a time of full employment. But as most people know by now, that rate doesn’t include people who “aren’t looking for work.” Add back in that group, and a much, much higher number is revealed of people out of work.

To put things another way: If our nation’s work rate today were back up to its start-of-the-century highs, well over 10 million more Americans would currently have paying jobs.

There is no way to sugarcoat these awful numbers. They are not a statistical artifact that can be explained away by population aging, or by increased educational enrollment for adult students, or by any other genuine change in contemporary American society. The plain fact is that 21st-century America has witnessed a dreadful collapse of work.

So how do we get to the point where we have more wealth, but slower growth and less work?

This is where Eberstadt starts to pull together some painful truths which many Americans, not just the elite, refuse to see, much less admit. These are the “nonmaterial” issues, specifically old-school notions of family breakdown and the decline of faith, but more recent and much graver concerns about society overall. They include a decline in general health, a drop in life expectancy, an increase in drug dependence, and an overwhelming number of ex-felons who have been precluded from the American Dream.

To start, the opioid epidemic has gone “mainstream” in America, with more people dying of drug overdoses since 2013 than from guns or traffic accidents. Eberstadt points to research by Alan Krueger, former chairman of the President’s Council of Economic Advisers, who found that “nearly half of all prime working-age male labor-force dropouts — an army now totaling roughly 7 million men — currently take pain medication on a daily basis.”

And whose paying for all these drugs? The federal government. The Census Bureau’s SIPP survey (Survey of Income and Program Participation), reports that “as of 2013, over one-fifth (21 percent) of all civilian men between 25 and 55 years of age were Medicaid beneficiaries. For prime-age people not in the labor force, the share was over half (53 percent).”

By the way: Of the entire un-working prime-age male Anglo population in 2013, nearly three-fifths (57 percent) were reportedly collecting disability benefits from one or more government disability program in 2013. Disability checks and means-tested benefits cannot support a lavish lifestyle. But they can offer a permanent alternative to paid employment, and for growing numbers of American men, they do. The rise of these programs has coincided with the death of work for larger and larger numbers of American men not yet of retirement age. We cannot say that these programs caused the death of work for millions upon millions of younger men: What is incontrovertible, however, is that they have financed it—just as Medicaid inadvertently helped finance America’s immense and increasing appetite for opioids in our new century.

“In 21st-century America,” Eberstadt concludes, “‘dependence on government’ has thus come to take on an entirely new meaning.”

Lastly, Eberstadt notes that about 90 percent of felons are free and living in American society today. He estimates that to be about 17 million men — or about one of every eight adult males living in the U.S.

Noting that this population is “roughly twice the total size of our illegal-immigrant population and an adult population larger than that in any state but California,” it begs the question, what is their opportunity in America?

Answer: Not good.

We might guess that their odds in the real America are not all that favorable. And when we consider some of the other trends we have already mentioned—employment, health, addiction, welfare dependence—we can see the emergence of a malign new nationwide undertow, pulling downward against social mobility.

Why does he guess that? Casual observation seems to work, but also falling numbers for geographic mobility, a drop in the churn rate of jobs (meaning the ability to move up the economic ladder as resumes are built), and the decline in the chance of achieving more than one’s parents did.

Where does this all lead? To a drop in social mobility — the ability to survive on merit and hard work, which is the heart of the America Dream.

Eberstadt notes that while America’s elite love to discuss “economic inequality,” that’s irrelevant to a lot of Americans. What does matter is the “reality of economic insecurity.” And if it took the 2016 election to wake up the wealthholders, well, then, the wake-up call is at least a start.

The Persistent Marriage Penalty and Its Impact on Family Formation

You thought this was resolved in the ’90s, didn’t you? It wasn’t.

“Almost one-third of Americans aged 18 to 60 report that they personally know someone who has not married for fear of losing means-tested benefits.”

That’s right, the marriage penalty still exists on families who receive government subsidies, and it is impacting more families as the safety net expands.

Now, the bias up the social ladder has traditionally been to assume that people who have kids without getting married are of questionable moral character because who would go have a baby without having a stable household, right? After all, studies show that children raised by their biological parents in married households have a likelier chance of success in school, a stable job, and upward mobility.

That notion of planning your marriage, then your family is outdated in a lot of communities, not least because when is it ever a good time to have a kid? So maybe the decision to not marry is not a question of moral repute, but in fact a question of public policy working against a loving family whose only commitment phobia is filling out the paperwork.

At least 43 percent of families with children 18 and under receive some kind of means-tested aid from the federal government, from Medicaid to Supplemental Nutrition Assistance Program funds. That number goes up to 47 percent for families with children five and under. And this is what they are likely to face if they marry.

… 82 percent of those in the second and third quintiles of family income ($24,000 to $79,000) face this kind of marriage penalty when it comes to Medicaid, cash welfare, or food stamps. By contrast, only 66 percent of their counterparts in the bottom quintile (less than $24,000) face such a penalty. …

Couples where each partner’s individual income is near the cut-off for means-tested benefits—are about two to four percentage points less likely to be married if they face a marriage penalty in Medicaid eligibility or food stamps. Most of these couples are in the second and third quintiles of family income for families with children two and under ($24,000 to $79,000).

Indeed, this recent report on the marriage penalty notes that couples’ combined income in that second and third quintile of earners ($24,000 to $79,000) could face penalties of lost benefits up to one-third of their income if they were to marry.

A valid question is why has the social safety net grown so large that families making nearly $80,000 are still receiving benefits? That may make sense if you’re talking about a family in Brooklyn or around the Beltway outside Washington, D.C., or  Honolulu, or San Francisco, for example, but that’s certainly not the situation in Indianapolis, Louisville, Omaha, Memphis, Tulsa, and so on.

The answer lies in the decision not to marry. If one unmarried person is reporting income to an agency, then the household earnings don’t get counted as $80,000, it only gets counted as the one family member’s income. A combined income would phase out benefits whereas a reported single income would qualify.

Certainly, no one wants to see anyone in need unable to receive the staples of shelter and food, but as the below infographic demonstrates, 59.7 percent of cities surveyed by Experian (click on it to enlarge) have a lower median income and a lower cost of living than the national average so many recipients can in fact afford to live without federal benefits.

Cost of living in America infogrpahic

The report does not challenge the expansion of the safety net to the lower-middle class, but it does raise the question of whether public policy discourages couples from marrying. And as the evidence shows, a significant minority of Americans say they have seen marriage ruled out because of the policies.

So how does government policy correct itself to not penalize lower-middle-class couples for being married when they start their family? The report makes four suggestions:

– In determining eligibility for Medicaid and food stamps, increase the income threshold for married couples with children under five to twice what it is for a single parent with children under five. Such a move would ensure that couples just starting a family do not feel pressured to forgo marriage just to access medical care and food for their families. The cost of this policy change would be limited, since it would only affect families with young children.

– Offer an annual, refundable tax credit to married couples with children under five that would compensate them for any loss in means-tested benefits associated with marrying, up to $1,000. This would send a clear signal that the government does not wish to devalue marriage and, for couples, it would help to offset any penalties associated with tying the knot.

– Work with states to run local experiments designed to eliminate the marriage penalty associated with means-tested policies. States could receive waivers to test a range of strategies to eliminate penalties in certain communities, and to communicate to the public that the penalties are no longer in force there. Successful experiments could then be scaled up to the national level in future efforts to reform means-tested policies.

– Encourage states and caseworkers working with lower-income families to treat two-parent families in much the same way as they do single-parent families. For instance, states could ease the distinctive work requirements that many have in place for two-parent families receiving cash welfare. Reforms such as this one would put two-parent and single-parent families on a more equal footing when it comes to public assistance. More generally, policymakers and caseworkers should try to eliminate policies and practices that effectively discriminate in favor of single-parent families.

Read the report on the marriage penalty’s impact on lower-middle income families.