The Complicated Lessons of Prohibition

In this issue, Ong and colleagues report on the effects of a 2006 Medicare ban on benzodiazepines for enrollees with Medicare Part D coverage. The ban was originally expected to save costs and reduce adverse drug effects. The authors found decreased benzodiazepine use but no reduction in adverse effects of the drug, and they report that overall costs for psychotropic medications increased. Other published reports on the benzodiazepine ban similarly suggest that clinical outcomes are not improved. The benzodiazepine ban is expected to be eliminated in 2013 under the Patient Protection and Affordable Care Act.

Several examples in U.S. policy history demonstrate the complex and often contrasting outcomes that occur after enactment of laws that ban certain practices. Perhaps most famous is the amendment to the U.S. Constitution in place from 1920 to 1933 that banned the sale, manufacture, and transportation of alcohol. This act, known as Prohibition, was controversial from the very beginning, and subsequent reports highlight the complex and competing issues during the pre-Prohibition and Prohibition eras. Temperance groups argued that alcohol sales promoted alcohol abuse, addiction, and deterioration of American families. Some religious groups identified alcohol use as a moral flaw. Politicians in the 1916 presidential elections were reluctant to alienate their political base on either side of the issue and chose not to address the topic directly. Physicians of the era often prescribed treatments that contained alcohol, and some medical professional societies lobbied for Prohibition's repeal. In addition, some have suggested that bias against immigrants was a prominent undertone in mainstream, U.S. temperance group efforts, mainly from the Anglo-Saxon population. Although Prohibition reduced alcohol use, positive social and health effects were overshadowed by a rise in crime and corruption. After intense controversy and public response to obvious and growing negative effects, Prohibition was repealed. It is generally acknowledged to have been a policy failure.

The benzodiazepine ban likewise is an act of policy that delivers on some intended effects but otherwise does not seem to reduce costs and may worsen health outcomes. Given that individuals with supplemental health insurance have access to benzodiazepines and are not affected by the benzodiazepine exclusion, the ban may widen health disparities between those with private versus public health coverage. As the authors note, the State of California may exclude benzodiazepines from future Medicaid coverage. Taken together, emerging evidence does not support the notion that a benzodiazepine ban helps troubled budgets or troubled patients. Additional studies are needed to evaluate clinical and economic impacts of medication restrictions and to inform health policy. In the meantime, the benzodiazepine ban, like Prohibition, appears to be a failed policy and should be eliminated.