health care in the public as compared with the private sector may explain why leadership on some quality improvement initiatives, such as reduction in the use of restraints, performance measurement, and consumer-oriented health care, is more often found in the public than the private sector.

Moreover, although access to M/SU health care for some individuals has improved over the past decade (Kessler et al., 2005; Mechanic and Bilder, 2004), there are still unique obstacles to accessing these services. Insurers continue to impose greater limits on M/SU health care coverage by requiring higher copayments and deductibles, limiting benefits (Bureau of Labor Statistics, 2003), and excluding coverage altogether if an injured individual was under the influence of alcohol or some other drug (Cimons, 2004). These cost and insurance issues are a leading reason reported by consumers for not receiving needed M/SU treatment (SAMHSA, 2004).

Further, individuals with substance-use illnesses themselves may impede their access to care in the marketplace. Individuals with substance-use problems and illnesses who do not experience recovery on their own typically do not seek treatment until their condition becomes so severe that they must do so, or they are compelled by workplace problems, criminal offenses, and the like (Weisner and Schmidt, 2001). In a 2001 national survey of individuals in recovery from alcohol or other drug illnesses and their families, 60 percent reported that denial of “addiction” or refusal to admit the severity of the problem was the greatest barrier to their recovery. Embarrassment or shame was the second most frequently cited obstacle (Peter D. Hart Research Associates, Inc., 2001). This is unfortunate because, as noted in Chapter 1, evidence shows that interventions delivered to patients with substance-use problems and illnesses can reduce substance use (Bernstein et al., 2005; Fleming et al., 1997).


More detailed analyses of the above issues are presented in the following chapters. As a result of these analyses, the committee made an overall finding and formulated an overarching recommendation concerning the relationship between M/SU and general health care. In addition, the committee made two overall findings and formulated a second overarching recommendation pertaining to the feasibility of applying the Quality Chasm framework to M/SU health care.

Relationship between M/SU and General Health Care

In conducting its work, the committee, like many expert panels before it, was confronted by the “destructive,” “artificial, centuries old separation

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