America's emergency rooms fill up each day with people who injure themselves while under the influence of alcohol or other drugs, yet few are ever referred to addiction treatment or counseling. The result: hundreds of millions of dollars in added health costs arising from the leading cause of injuries.

To stem this flood, a number of communities participating in Join Together's Demand Treatment! project, including San Diego, Calif., and New Haven, Conn., have set up alcohol and other drug screening programs for ER patients. Yet arcane insurance laws on the books in 42 states provide a major barrier to those who want hospitals to adopt screening for all trauma patients.

The National Association of Insurance Commissioners' (NAIC) Uniform Accident and Sickness Policy Provision Law (UPPL), initially adopted more than a half-century ago, states that health insurers "shall not be liable for any loss sustained or contracted in consequence of the insured's being intoxicated or under the influence of any narcotic unless administered on the advice of a physician." In other words, if a patient is found to be drunk or high when checked by an ER doctor, their insurer can legally refuse to pay for their medical care.

But the only law that works in this case is that of unintended consequences, according to Larry Gentillello, M.D., chairman of the trauma department at Beth Israel Deaconess Medical Center in Boston.

Measuring a patient's blood-alcohol content (BAC) would be a quick and easy way for ER doctors to determine if alcohol is involved in an injury and if a referral to addiction treatment is warranted. "It's a lot easier to do a BAC than an interview," Gentillello points out.

But the catch-22 is that if a measurable BAC is detected, the hospital risks not being paid for its services. "If the trauma surgeon screens the patient, then there's no payment," Gentillello tells Join Together. "They know this, and so they don't do it.

"The only impact of [the UPPL] law is to sweep the problem under the rug."

The end result is that insurers not only are paying claim after claim for alcohol- and other drug-related injuries, but patients and doctors are missing out on a major opportunity to intervene and prevent further ER visits. "There's a teachable moment when you're pulled out of a wreck," says Gentillello.

For example, one study found that alcohol and other drug use initially fell both among trauma patients who received counseling and among those who did not. But a year after their injury, patients who were screened continued to drink less and take fewer drugs, while those in the control group went back to their unhealthy behaviors.

Gentillello argues that screening is one of the few remaining ways that U.S. emergency rooms -- already the best in the world -- can cut injury deaths and trauma recidivism. Thanks to advances in lifesaving equipment and procedures, "We've essentially topped out in preventing death among ER patients," he says. "The only way to reduce injuries further is through prevention."

The potential benefits of widespread ER screening for addiction are immense, says Gentillello. Up to 70 percent of all trauma victims are under the influence of alcohol or other drugs, and studies have shown that addiction-oriented interventions with trauma patients can cut hospital readmissions nearly in half.

"If we screen and offer intervention to trauma patients, we can really reduce the recurrence of injury. But there's a real reluctance among trauma centers to get involved," Gentillello said.

Advocates for ER screenings for alcohol and other drug use, including the American Society for Addiction Medicine, have been working to get the UPPL laws repealed. They've made some significant headway. In March 2001, the National Conference of Insurance Legislators (NCOIL) adopted a resolution calling for repealing the alcohol and other drug provisions of the UPPL, calling the laws "anachronistic" and saying they "provide a strong financial disincentive to screen patients for substance-abuse problems, resulting in less than five percent of trauma patients screened for alcoholism and provided with the necessary counseling."

The NCOIL resolution estimated that screening for alcohol in ERs could save $327 million in direct medical costs over five years.

In June 2001, the NAIC, acting on the recommendation of NCOIL, voted unanimously to repeal the UPPL provision and adopted a new model law that bars insurers from denying payment on the basis of intoxication.

However, the insurance industry vigorously opposed the repeal of the UPPL provisions at the NAIC meeting, leading addiction advocates to worry that insurers also will continue to work to block the legislation needed to repeal the laws on the state level. The state of Maryland recently repealed its UPPL statute, and the Vermont legislature is considering repeal legislation. But insurers, represented by the Health Insurance Association of America (HIAA), remain unswayed by the fiscal arguments presented in favor of repeal.

Joe Luchok, communications manager of HIAA, acknowledges that the UPPLs could prevent trauma physicians from screening patients for alcohol or other drugs. "I could see where that would be a problem," he tells Join Together.

But, Luchok adds, "We have to represent our members on a cost basis. We could come to the conclusion that it might be more cost-effective not to do this at all. But we're not at that point yet. No one has made a compelling argument that [the current UPPL law] is something actually costing companies money."

Still, Gentillello remains hopeful that the day will come soon when all ER patients are screened and appropriately referred to treatment. "There are only about 150 Level 1 trauma centers in the U.S., so it's doable," he says.

Editor's note: To view a map of states with UPPL laws on Join Together Online, click here: www.jointogether.org/sa/action/dt/thefacts/snapshots/state2/

To view a list of the 42 states with UPPL laws, click here.