A conversation with Keith Humphreys on January 14, 2014

Participants

• Keith Humphreys — Professor and Section Director for Mental Health Policy, Stanford University
• Cari Tuna — Co-Founder, Good Ventures

Note: These notes give an overview of the major points made by Dr. Keith Humphreys.

Summary

Good Ventures spoke to Dr. Keith Humphreys as part of its exploration of opportunities in policy-oriented philanthropy. The conversation focused on Dr. Humphreys’ own work on drug policy and mental health, including a new mental health policy section he’s starting at Stanford University, which will train academics, students and medical professionals to engage with policymakers.

Drug policy

Drug policy is a space where philanthropy is not very active but where it could have an impact.

Corporate interests in alcohol and tobacco have helped shape policy in ways that are not in the interest of public health. Alcohol and tobacco are subject to modest regulation in the U.S. and even weaker regulation internationally. U.S. federal alcohol taxes have not been increased since 1991 and have been decreasing as a function of inflation since then. International trade agreements often help tobacco producers. There are four countries in sub-Saharan Africa that have identical alcohol policies because they were all written by the alcohol industry.

Weak regulation has also helped the prescription drug industry at the expense of public health. The U.S. cold medicine industry has opposed restrictions related to the over-the-counter sale of medicines that can be used to produce methamphetamine. 

There are few groups actively opposing corporate interests in this area, and, in particular, there is little philanthropy dedicated to improving alcohol policy.

There are too many people in prison, many of them with drug and alcohol problems.

The majority of prisoners do not fit the simplistic framework of “psychopaths or innocent martyrs” that tends to dominate discourse about criminal justice: Most have problems worthy of treatment and pose a safety threat to other people The problem of illegal drugs has been oversimplified, leading people to suggest ineffective solutions such as full legalization on the one hand or mass incarceration on the other. States, which manage over 90% of the prison system, should be encouraged to adopt programs that respond more effectively to people who abuse illegal drugs, such as “swift and certain” sanctions. This work is difficult and involves bringing together parties that may not agree with one another, such as judges, police, and doctors. Dr. Humphreys spent a year promoting and presenting research on “swift and certain” sanctions to the British Parliament. His efforts helped result in tripartisan passage of legislation establishing the program in England.

Mental health

The life expectancy of an individual with serious mental illness, such as bipolar disorder or depression, is about 15-25 years shorter than that of an individual without serious mental health illness. This is largely due to problematic health policies, which, for example, have created a lack of access to care for certain populations.

Mental health policy section at Stanford

Dr. Humphreys and the other members of the section seek to be a non-partisan source of information and evidence-based solutions for policymakers in areas including addiction, mental health, violence, and criminal justice. This reputation has helped him form relationships with politicians on both sides of the aisle, a difficult task in today’s political climate. Dr. Humphreys has learned how to influence policy, by working with members of Congress, serving in the White House, forming coalitions, writing editorials, testifying to legislative bodies and developing policy briefs. Policy briefs and editorials are important ways to publicize issues and influence policy. Dr. Humphreys currently receives more requests for help from policymakers than he can handle.

In the past month, Dr. Humphreys has founded a mental health policy section in the Department of Psychiatry and Behavioral Sciences at Stanford University. The section is intended to teach other medical professionals how to engage with policymakers. The section will include medical students, residents, and six other faculty members.

The goal of the section is to use policy channels to improve the safety and quality of life for families facing mental illness and addiction by providing objective, evidence-based information to policymakers, whose views on mental health are often based on anecdotal information. The section will not endorse particular candidates or comment on subjects outside its areas of expertise.

The section will form relationships with and assist policymakers when approached for help, e.g. by advising on the writing of legislation, connecting policymakers from different states, and helping academically-based experts prepare to speak at public hearings. The section will not focus on commissioning research, because large amounts of funding for research are already available to academics. Rather, it will focus on translating the findings of research to increase policy impact, an endeavor in which few academics are engaged. Many studies do not have an impact, including those published in prominent journals. For example, the Antihypertensive and Lipid Lowering Heart Attack Trial (ALLHAT), a large treatment trial that cost roughly $130 million, had little practical impact on the health care system.

Dr. Humphreys has just begun fundraising for the section, which will rely on philanthropic funding. It cannot be funded by the National Institute of Health because it aims to work with policymakers. Ideally, philanthropists would commit funding to a few issues over a few years. The majority of this funding would be used to free up medical and academic professionals to engage with policymakers.

Possible areas of focus

Possible areas of focus for the mental health policy section include:

• Reducing incarceration of people with mental illness and substance abuse problems. Progress has been made on this front; the incarceration rate and the number of people on probation or parole have declined in each of the past three years after having increased for the previous 35 years, but there is more work to be done.
• Increasing public and private insurance coverage, including Medi-Cal, for mental illness and substance abuse. A large number of individuals with mental illness do not have access to affordable care. Great progress has been made in this area, but there is more work to be done to implement the expansion of insurance coverage.
• Disseminating alternatives to prison that deal with people who abuse substances and are a threat to public safety, such as 24/7 sobriety programs, Hawaii’s Opportunity Probation with Enforcement (HOPE) program, and drug courts.
• Establishing methamphetamine-resistant cold medicine as the standard in “meth belt” states such as West Virginia and Kentucky. The large drug companies that produce meth-extractable pseudoephedrine are more politically powerful than the small companies that produce resistant formulations. Those working to establish resistant-medications as the standard are engaging directly with legislators and writing op-ed pieces, among other actions.
• Ending reckless prescribing of medicines. One way to achieve this is to establish prescription monitoring programs to prevent individuals from receiving prescriptions from different doctors that have dangerous interactions or allow for abuse. In West Virginia, duplicate prescriptions have been responsible for roughly 20% of deaths from opioid overdose. Corporate interests make it difficult to end reckless prescribing.
• Raising alcohol taxes, which are too low. This would be hard to accomplish.  As an alternative to increased taxation, there is currently some work in the U.K. and Canada on establishing a minimum unit price for alcohol in order to reduce the availability of cheap alcohol.
• Developing more sensible tobacco taxes. For example, tobacco taxes are currently inconsistent across states, creating large black markets. It will be difficult to make progress on this issue because states have to give up some sovereignty to set taxes at similar rates.
• Ending lifetime penalties that bar ex-convicts, specifically those convicted of drug felonies, from receiving welfare and federal student loans and from working in certain professions.
• Promoting the celebration of recovery from addiction. This is “symbolic work” that involves more publicity than policy. Symbolic work made important contributions to the fight against HIV/AIDS in the gay community. In the addiction space, a lot of this work has been done through the President’s National Drug Control Strategy, which was created during Dr. Humphreys’ tenure at the Office of National Drug Control Policy.
• Passing legislation to increase access to naloxone, a drug that helps prevent overdose deaths. The West Virginia legislature is considering a bill that would enable police, firefighters, shelter workers, and other first responders to carry and administer naloxone. Other states have passed or are considering passing bills to increase access to the drug and train family members of addicts to administer it.
• Placing suicide barriers at high incident sites such as the Golden Gate Bridge. Dr. Humphreys’ team is providing policy strategy advice to the group that is leading this effort. Suicide barriers have decreased the population rate of suicide.
• Banning the sale of tobacco at Stanford University, one of the few universities that still sells the drug on campus. This is a small-scale student effort for which Dr. Humphreys is providing some assistance.   Shortly after this interview was completed, Stanford did in fact ban tobacco sales on campus. 
• Establishing an annual, two-day “policy knowledge exchange” at Stanford University to advise new state legislators and gubernatorial advisors on issues such as Medicaid, the prison system, mentally-ill prison populations, illegal drugs, and state efforts to lower suicide rates and improve mental health in schools. A policy knowledge exchange would be important because, as a result of term limits, many state legislators do not have enough expertise in areas such as health, mental health, and child development. They tend to be informed by lobbyists and staff members who may not always provide objective, evidence-based information. Many state legislators welcome this kind of assistance. Meeting with state legislators is important because many programs are state-run, including prisons, law enforcement, Medicaid, and education. The Harvard Kennedy School has been organizing similar meetings for new members of Congress for years.

Strategic cause selection

There are many important causes, but not all of them are good opportunities for philanthropy. Dr. Humphreys selects causes based partly on whether an issue is ripe for reform. Dr. Humphreys also looks for opportunities based on the passions and expertise of his team and on existing relationships with key players. Dr. Humphreys’ team has relationships with the offices of multiple members of California’s Congressional Delegation l as well as with state legislators in California and around the U.S..  Internationally, the team has connections to the U.K. Parliament and the World Health Organization.

Drug manufacturers have consistently run successful campaigns against efforts to limit access to cold medicines that meth can be derived from. This issue was discussed in the Mother Jones article, “Merchants of Meth: How Big Pharma Keeps the Cooks in Business.” The development of meth-resistant cold medicines in the last two years has created an opportunity to reduce meth production without requiring that cold medicines be prescription-only. States can incentivize drug manufacturers to switch to resistant formulations by banning the sale of non-resistant drugs. Now that resistant formulations exist, it will be harder for the industry to argue against this type of reform. In West Virginia in 2011, the House of Delegates voted heavily in favor of limiting access to non-resistant drugs but the Senate vote ended with a tie, due to high levels of spending by the drug industry. The next three to four months will be telling as to whether progress will be made in this area. Philanthropy could help tip the balance in favor of public health.

Increasing insurance coverage and reimbursement rates for drug and alcohol treatment is another example of an area that was ripe for reform; the campaign was successful in part because it overlapped with the Obama administration’s campaign for the Affordable Care Act, which had a lot of momentum behind it.

The issue of post-conviction penalties at the federal level is less ripe for reform because its chief proponent, Congressman George Miller, will not be seeking reelection in 2014.

Other people to talk to

Dr. Humphreys recommended that Good Ventures talk to Harold Pollack, a professor at the University of Chicago School of Social Service Administration, about opportunities for philanthropy in drug policy and criminal justice reform.