By Hannah Rahim
The Americans with Disabilities Act (ADA) prohibits health care organizations that provide services to the public from discriminating against persons with disabilities. Although substance use disorder can be a disability under the ADA, there are limitations in the scope and enforcement of these ADA protections. Further action is needed to prevent discrimination in health care services towards persons with substance use disorder.
Health care discrimination toward persons with substance use disorder
People experiencing substance use disorder often face discrimination and stigma in the medical setting. This discrimination is rooted in misinformation and a view of substance use disorder as a personal failing, rather than a medical condition. Consequences of this discrimination and stigma include reduced access to care, receiving poorer quality of care, or refraining from seeking necessary care.
An example of this discrimination is evident in a 2020 settlement agreement between the Department of Justice (DoJ) and Massachusetts General Hospital. Here, the DoJ found that Massachusetts General Hospital discriminated under the ADA by denying a patient, Bryan, the opportunity to be listed on the lung transplant waiting list because he was taking Suboxone, an FDA-approved treatment for opioid use disorder. Bryan had cystic fibrosis that had progressed to the stage that he needed a transplant to survive. Bryan ultimately obtained a transplant at the University of Pennsylvania. As part of the settlement, Massachusetts General Hospital paid $170,000 to Bryan and $80,000 to his mother, in addition to agreeing to adopt non-discrimination policy and provide ADA training.
The DoJ has reached settlements with several other health care providers over the past years, including Selma Medical, Charwell Operating Nursing Facility, Athena Health Care Systems, Alliance Health, New England Orthopedic Surgeons, and King’s Daughters Medical Center, also concluding that the providers violated the ADA by refusing health care services to patients because they were taking medication for their substance use disorder.
Substance use disorder as a disability under the ADA
As described above, the ADA offers an avenue to prevent discrimination towards persons with substance use disorder. But it is not without limitations. Substance use disorder can qualify as a disability under the ADA because it substantially limits one or more major life activities and interferes with the operation of key bodily functions. However, ADA protections only extend to individuals who are in recovery and who are no longer using illegal drugs. The ADA does include an exception for health care services, which provides that someone cannot be denied medical services due to their current use of illegal drugs if they would otherwise qualify for these services. But case law or guidance to clarify the scope of this exception is minimal. Enforcement of this provision is thus limited because of this lack of guidance, in combination with the fact that federal litigation can take years to resolve while health care needs are often time-sensitive.
Also, courts have held that there is no per se rule that categorizes individuals recovering from substance use disorder as disabled and that a case-by-case evaluation is needed. This interpretation allows for judicial discretion, which can create inconsistency and unpredictability in disability protections.
Recommendations to reduce health care discrimination towards persons with substance use disorder
The government and health care organizations can take steps to minimize discrimination towards persons with substance use disorder in the medical context, at both the systemic and individual levels.
The U.S. Department of Health and Human Services or the DoJ should provide guidance clarifying the ADA protections for persons with substance use disorder and, in particular, circumstances under which persons who currently use illegal drugs are protected by the ADA (i.e., the scope of the health care services exception). This guidance should specify what evidence should be required of health care providers to justify refusing treatment of persons with substance use disorder (e.g., clear medical evidence of harmful interactions between substances consumed and the treatment). They should also encourage expedited review of health care discrimination cases, given the time-sensitive nature of health care needs.
Government agencies could also launch hotlines or online complaint systems to monitor health care discrimination and provide support to persons with substance use disorder who experience this discrimination. Such support could include assistance with pursuing legal remedies or with accessing services through other avenues. For example, the New York State Attorney General’s Health Care Bureau manages a helpline that supports patients with accessing health care services.
Health care organizations can also contribute to reducing discrimination by seeking to combat stigma and bias toward persons with substance use disorder. Organizations can encourage clinicians to use destigmatizing language and can implement training programs to challenge biases among health care providers. Additionally, organizations should consider how their policies may result in discrimination towards patients with substance use disorders and how these policies can be modified to improve health equity.
