Alcohol Exclusion Laws and Its Drawbacks

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INTRODUCTION
Since the repeal of the 18th Amendment in 1933, alcohol consumption has become prevalent among many Americans. Alcohol intoxication is an increasing contributor to emergency room visits wherein individuals present to the emergency department (ED) in an inebriated state,  often with secondary injuries or severe medical co-morbidities related to alcohol poisoning. The ED is a stressful environment with providers working under taxing conditions while triaging difficult cases. Alcohol related visits contribute to this added stress for staff given that intoxicated individuals increase wait times for the ED, use up valuable resources, and have the capacity to act violently towards providers. As one nurse puts it, some intoxicated individuals  present with “an aggressive state, perhaps have been in a fight, blood everywhere, careening  around the place – it can make things very difficult.”[1] To combat these circumstances, thirty-four States including the District of Columbia have implemented a countermeasure recognized as Alcohol Exclusion Laws (AELs). 
AELs reduce or cut insurance coverage of certain visits to the ED if the cause of the visit is due to alcohol intoxication.[2] The vast implementation of this law is derived from the idea of individual decision making, that it is an individual’s choice to consume alcohol, and therefore they hold a personal responsibility for their intoxication. By using insurance coverage as a leverage, the law aims at reducing the number of ED visits relating to alcohol intoxication, saving resources, and deterring irresponsible drinking. While the intention behind AELs aims for positive change, it is unethical to use AELs, a form of financial leverage, to address certain problems within emergency medicine. 
ANALYSIS
Stigma is prominent in almost all substance abuse cases including those seen with alcohol intoxication. Many patients feel embarrassment or shame when seeking medical attention for a condition that was brought on by alcohol misuse. A personal account by Jonathan Hunt Glassman, a former alcoholic and NBC contributor, emphasizes on this negative bias. He knows firsthand how unsettling an ED visit can be. He felt demoralized from a superficial prognosis  made by a nurse on his complex alcohol abuse condition, in which the nurse said, “You need to  stop drinking.”[3]
Whether it be from shame or insecurities about an individual’s condition, the stigma behind substance abuse cases in the emergency department and the daunting task of asking for help can turn a lot of patients away from seeking and receiving medical treatment. The implementation of Alcohol Exclusion Laws can amplify this already present stigma. A study conducted by the National Institute of Health (NIH) analyzed States that implemented and continued to enforce Alcohol Exclusion Laws and the stigma in those states surrounding alcohol-related ED visits. The result from the study showed that AELs correlated with an increase in stigmatization regarding medical attention for alcohol-related incidents, and that AELs “negatively impact people’s willingness to seek medical care after alcohol-related injuries or  illnesses.”[4] Both the NIH study and the personal account by Hunt-Glassman go on to show that  AELs have the adverse effect of reinforcing the stigma surrounding alcohol cases in the ED.  While the idea behind AELs is in good faith, it contributes to the stigma. This contribution ethically challenges the idea that the emergency room is a space where the treatment of injuries is carried out without biases infringing on such medical care. The mission of EDs is to provide medical care to anyone in need. AELs have the effect of discouraging these patients from seeking help with the unintended consequence of doing them harm. 
A point of argument for the implementation of AELs is that it is the individual’s choice to be intoxicated and therefore justifiable that an individual receives less insurance coverage for medical expenses from a preventable intoxication. The idea of it being an individual choice to become intoxicated is one of the strongest supports for these exclusion laws. However, it is unjust to assume that all alcohol intoxications come by choice. Instances that disprove this assumption include both the college party scene and bar scene. Spiked drinks significantly increase alcohol concentration and can cause any responsible drinker to become intoxicated without intention or against their will. Additionally, alcoholic beverages served in various social gatherings like those in or around college campuses may not have a clear percentage of alcohol determination. Liquor containing high percentages of alcohol, such as Everclear which contains up to 190 proofs, are often masked by sweeteners and flavorings. Cocktails like these can cause a person to become dangerously intoxicated without their realization or intention. Some may argue that consuming an alcoholic beverage still holds accountability, that the person should be aware of the potential for a tampered drink, and therefore AELs should remain in use to deter this. However, like any law, AELs needs to have defined restrictions and/or exemptions. If the individual choice argument is used in favor for AELs, then how far reaching can the laws be applied? An attorney who specializes in these exclusion laws believes that AELs often offer more ambiguity than clarification when it comes to insurance policy, which leads to further ways insurance claims can be denied.[5]
CONCLUSION
In summary, the idea behind the use of Alcohol Exclusion Laws aims to reduce intoxication cases in the ED, however, there are drawbacks and aspects of this law that challenge the ethics of seeking medical care from the emergency department. The present stigma surrounding going to the ED for alcohol-related emergencies is already prevalent in hospitals across the country. When applying AELs, the present stigma may be magnified and further push the idea that seeking help for alcohol-related emergencies is shameful and embarrassing for patients, and therefore should be punished via financial means. Secondly, one of the main justifications for AELs is the idea that it is a deliberate intention to become intoxicated. It isn’t always the intention of individuals to get drunk when they choose to consume alcohol. There are additional factors that may play a part to exonerate a person’s accountability. It is difficult for people to recall the specifics of a situation when they become intoxicated; in some cases, accountability cannot be determined and the used of AELs can become unjustified. Overall, Alcohol Exclusion  Laws try to solve the issue of alcohol incidents in a way that produces more detriment than progress. A method to combat the issue of irresponsible drinking and intoxication in the emergency room within the US should not use AELs and financial leverage as one of its forefronts. In fact, a study that based its findings obtained from the Behavioral Risk Factor  Surveillance System nationwide survey that spanned twenty-four years from 1993-2017,  showed no real impact on binge drinking or increased alcohol consumption.[6] Given the downsides to AELs and its proven non-significant effects, several States have already repealed their AELs. For all these reasons, it would be beneficial to find an alternate method to address alcohol related issues within healthcare.
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[1] Gregory, A. (16 Jun 2014). Nurses say drunk patients should be banned from A&E as ‘waste of resources’ UK:  Mirror. https://www.mirror.co.uk/news/uk-news/nurses-say-drunk-patients-should-3706280 2(Jan 2008).
[2] Alcohol Exclusion Laws. National Highway Traffic Safety Administration. https://www.nhtsa.gov/sites/nhtsa.gov/files/810885.pdf.
[3] Glassman, J.H. (28 Apr 2022). Why don’t alcoholics get prescribed the medication they need?. NBC.  https://www.nbcnews.com/think/opinion/alcohol-related-deaths-er-visits-rose-covid-solution-use- rcna26425.
[4] Azagba, S., Ebling, T., Hall, M., (2023). Health claims denial for alcohol intoxication: State laws and structural stigma. Wiley Online Library. https://onlinelibrary.wiley.com/doi/10.1111/acer.15153. 
[5] (7 Sep 2021). The Alcohol Exclusion Chart Denied Life Insurance Claim. https://www.lifeinsuranceattorney.com/blog/2021/september/the-alcohol-exclusion-state-chart-denied-life-in/.
[6] Azagba, S., Shan, L., Ebling, T., Wolfson, M., Hall, M., Chaloupka, F., (26 Nov 2022). Does state repeal of alcohol  exclusion laws increase problem drinking? National Institutes of Health. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10099925/.


INTRODUCTION
Since the repeal of the 18 th Amendment in 1933, alcohol consumption has become prevalent among many Americans.Alcohol intoxication is an increasing contributor to emergency room visits wherein individuals present to the emergency department (ED) in an inebriated state, often with secondary injuries or severe medical co-morbidities related to alcohol poisoning.The ED is a stressful environment with providers working under taxing conditions while triaging difficult cases.Alcohol related visits contribute to this added stress for staff given that intoxicated individuals increase wait times for the ED, use up valuable resources, and have the capacity to act violently towards providers.As one nurse puts it, some intoxicated individuals present with "an aggressive state, perhaps have been in a fight, blood everywhere, careening around the place -it can make things very difficult." 1 To combat these circumstances, thirty-four States including the District of Columbia have implemented a countermeasure recognized as Alcohol Exclusion Laws (AELs).
AELs reduce or cut insurance coverage of certain visits to the ED if the cause of the visit is due to alcohol intoxication. 2The vast implementation of this law is derived from the idea of individual decision making, that it is an individual's choice to consume alcohol, and therefore they hold a personal responsibility for their intoxication.By using insurance coverage as a leverage, the law aims at reducing the number of ED visits relating to alcohol intoxication, saving resources, and deterring irresponsible drinking.While the intention behind AELs aims for positive change, it is unethical to use AELs, a form of financial leverage, to address certain problems within emergency medicine.

ANALYSIS
Stigma is prominent in almost all substance abuse cases including those seen with alcohol intoxication.Many patients feel embarrassment or shame when seeking medical attention for a condition that was brought on by alcohol misuse.A personal account by Jonathan Hunt Glassman, a former alcoholic and NBC contributor, emphasizes on this negative bias.He knows firsthand how unsettling an ED visit can be.He felt demoralized from a superficial prognosis made by a nurse on his complex alcohol abuse condition, in which the nurse said, "You need to stop drinking." 3Whether it be from shame or insecurities about an individual's condition, the stigma behind substance abuse cases in the emergency department and the daunting task of asking for help can turn a lot of patients away from seeking and receiving medical treatment.The implementation of Alcohol Exclusion Laws can amplify this already present stigma.A study conducted by the National Institute of Health (NIH) analyzed States that implemented and continued to enforce Alcohol Exclusion Laws and the stigma in those states surrounding alcohol-related ED visits.The result from the study showed that AELs correlated with an increase in stigmatization regarding medical attention for alcohol-related incidents, and that AELs "negatively impact people's willingness to seek medical care after alcohol-related injuries or illnesses." 4Both the NIH study and the personal account by Hunt-Glassman go on to show that AELs have the adverse effect of reinforcing the stigma surrounding alcohol cases in the ED.While the idea behind AELs is in good faith, it contributes to the stigma.This contribution ethically challenges the idea that the emergency room is a space where the treatment of injuries is carried out without biases infringing on such medical care.The mission of EDs is to provide medical care to anyone in need.AELs have the effect of discouraging these patients from seeking help with the unintended consequence of doing them harm.
A point of argument for the implementation of AELs is that it is the individual's choice to be intoxicated and therefore justifiable that an individual receives less insurance coverage for medical expenses from a preventable intoxication.The idea of it being an individual choice to become intoxicated is one of the strongest supports for these exclusion laws.However, it is unjust to assume that all alcohol intoxications come by choice.Instances that disprove this assumption include both the college party scene and bar scene.Spiked drinks significantly increase alcohol concentration and can cause any responsible drinker to become intoxicated without intention or against their will.Additionally, alcoholic beverages served in various social gatherings like those in or around college campuses may not have a clear percentage of alcohol determination.Liquor containing high percentages of alcohol, such as Everclear which contains up to 190 proofs, are often masked by sweeteners and flavorings.Cocktails like these can cause a person to become dangerously intoxicated without their realization or intention.Some may argue that consuming an alcoholic beverage still holds accountability, that the person should be aware of the potential for a tampered drink, and therefore AELs should remain in use to deter this.However, like any law, AELs needs to have defined restrictions and/or exemptions.If the individual choice argument is used in favor for AELs, then how far reaching can the laws be applied?An attorney who specializes in these exclusion laws believes that AELs often offer more ambiguity than clarification when it comes to insurance policy, which leads to further ways insurance claims can be denied. 5

CONCLUSION
In summary, the idea behind the use of Alcohol Exclusion Laws aims to reduce intoxication cases in the ED, however, there are drawbacks and aspects of this law that challenge the ethics of seeking medical care from the emergency department.The present stigma surrounding going to the ED for alcohol-related emergencies is already prevalent in hospitals across the country.When applying AELs, the present stigma may be magnified and further push the idea that seeking help for alcohol-related emergencies is shameful and embarrassing for patients, and therefore should be punished via financial means.Secondly, one of the main justifications for AELs is the idea that it is a deliberate intention to become intoxicated.It isn't always the intention of individuals to get drunk when they choose to consume alcohol.There are additional factors that may play a part to exonerate a person's accountability.It is difficult for people to recall the specifics of a situation when they become intoxicated; in some cases, accountability cannot be determined and the used of AELs can become unjustified.Overall, Alcohol Exclusion Laws try to solve the issue of alcohol incidents in a way that produces more detriment than progress.A method to combat the issue of irresponsible drinking and intoxication in the emergency room within the US should not use AELs and financial leverage as one of its forefronts.In fact, a study that based its findings obtained from the Behavioral Risk Factor Surveillance System nationwide survey that spanned twenty-four years from 1993-2017, showed no real impact on binge drinking or increased alcohol consumption. 6Given the downsides to AELs and its proven non-significant effects, several States have already repealed their AELs.For all these reasons, it would be beneficial to find an alternate method to address alcohol related issues within healthcare.