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But, the problem does not rest solely upon the shoulders of health care providers. 

 What has been sorely needed in the discussions of how to contain health care costs is a 

 discussion of how we can improve our health and reduce the morbidity that leads to those 

 costs. To do so, we need to acknowledge the importance of substance abuse as a major factor 

 in causing and complicating the health problems of our citizens. As a nation, we have not yet 

 made the commitment to address the problem of substance abuse. For example, the U.S. is the 

 only industrialized nation among a group surveyed which had a tobacco tax that amounted to 

 less than 50% of the cost of a pack of cigarettes. U.S. total taxes amounted to only an average 

 of 30%. In addition, most other countries have considerably greater regulation on all forms 

 of tobacco advertising than does the U.S. Among 19 countries rated in terms of their control 

 of advertising, the U.S. ranked 18th.' 



Nor have we invested sufficiently in the research necessary to identify and target 

 effective interventions, or even to imderstand fully the relationship between various substances 

 and illness. As we found in our own work, while there has been extensive epidemiologic 

 research linking cigarette smoking and a variety of diseases, fewer studies relate alcohol to 

 disease, and even less is known about the full impact of illegal drugs. 



Whether, in the end, we discover that substance abuse is responsible for 20 or 30 

 percent (or more) of health care costs may be less the issue than the fact that we already know 

 that literally hundreds of billions of dollars are spent each year on health care as a result of 

 substance abuse. As a result, the ftiture solvency of the Medicare Trust Fund is inextricably 

 intertwined with what we do today to reduce substance abuse in all its forms-among our 

 citizens. Preventing diseases that result from substance abuse and prolonging a healthy life for 

 the elderly can be a much more potent weapon against rising Medicare expenditures than the 



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