Getting upstream of the costs

Same Facts is pushing a RAND report on 24/7 Sobriety in South Dakota.  It is showing incredible results for improved health and safety outcomes.

Examining the 24/7 Sobriety Program in South Dakota, which started as a pilot in 2005, researchers found that county implementation of the program was associated with a 4 percent drop in deaths at the county level.

The South Dakota 24/7 Sobriety Program requires that individuals with an alcohol-involved offense undergo twice-a-day breathalyzer tests, typically once in the morning and once in the evening, or wear continuous alcohol monitoring bracelets. Individuals who fail or skip required tests are immediately subject to a short jail term, typically a day or two for a failed test.

Nearly 17,000 individuals — nearly 3 percent of the state’s adult population — participated in the 24/7 program between January 2005 and June 2011. Nearly half of the participants were enrolled after a repeat DUI offense, while others were enrolled after a first-time DUI offence or being charged with assault or domestic violence….

To examine whether the program was associated with changes in mortality, researchers analyzed county-level mortality data from January 2000 through June 2011, and took advantage of the fact that counties implemented the strategy at different points in time…..

The association was evident not only for total deaths, but also among conditions sensitive to alcohol use, including circulatory conditions.

Mark Kleiman ( a big supporter of 24/7 Sobriety and more generally swift/certain/small punishment regimes) at Vox makes another point on cost effectiveness:

The program costs less than $2 per participant per day; offenders are required to bear that cost, presumably out of the money they would otherwise spend on alcohol.

Doing some very quick back of the envelope calculations, this is a $12 million dollar a year program at most ($2 per day per participant *17,000*365).  It works out to be a public health investment of no less than a penny per person per week.  This is a massive overestimate as the program was evaluated over a six year period and people came in and out of the program.  But let’s stick with $12 million as the worst case scenario is massive illuminating anyways.

The program only had to avoid two deaths per year or add 120 QALY improvements to be cost effective as a public health measure.  If the 4% reduction in mortality runs through verification, the averted deaths are orders of magnitude higher than the minimal needed to be a break even proposition.

This is an extreme example of how public health programs can be used to divert medical expenses.  South Dakota’s hospitals are most likely seeing a healthier population than they otherwise would have been seeing.  There would be fewer car crashes, fewer cirrhosis cases,  fewer cardiovascular failures than the counterfactual of having drunk drivers still drinking.  Substance abuse is a known cost driver in risk adjustment, and it is often a co-morbidity multiplier where it makes treating other issues harder and more expensive.  From a public health perspective society paying a few pennies per person per month for this type of public health intervention is a massive win.

It is a win at the immediate outcome level, and it is a win at avoiding sending people to limited detox and rehab beds at $1,000 or more per bed per night.


34 replies
  1. 1
    Yutsano says:

    So which Republican votes to kill it first becuz FREEDUMB?

  2. 2
    Russ says:

    Also the ancillary effects on household members and offspring going forward for years and continuing to lower alcohol use levels is something that………..Richard? can be measured?

  3. 3
    satby says:

    Sounds like a great program. Which is why I doubt it’ll ever be widely implemented. Hope I’m wrong about that.

  4. 4
    Eric U. says:

    Of course, in red states, the cops would show up and kill the offender

  5. 5

    I couldn’t find any data on how long the participants stay in this program. It’d be interesting to see the health impacts of those who’ve left he program.

  6. 6
    Tim F. says:

    Sure, but on the other hand some people have to be sober in South Dakota.

  7. 7

    @Xboxershorts: I did not see any data either. Usually supervised release for DUI and assault is not that long <2 years

  8. 8
    Ex Libris says:

    What the anti-government yahoos have succeeded in doing is making everyone think “12 million dollars” could never be a bargain of any kind, because “millions of dollars”. Convincing people to recognize short-range small expenses in favor of order-of-magnitude later costs is for some reason nearly impossible, even though it’s very explainable, easy to show on a chart, or whatever. I think they have personalized it somehow – they get people to think it’s as if you, personally, have to come up with 12 million dollars to fund this program. I guess that’s how propaganda works.

  9. 9

    @Ex Libris: It’s being sold as a money saving program. The individual is paying for their own monitoring and the state is avoiding a certain number of $30,000 to $50,000 per person per year in prison sentences. A few nights in jail and then long term behavior modification is way cheaper than a prison sentence and traditional probation monitoring.

  10. 10
    WereBear says:

    @Ex Libris: An excellent point!

    It is my working theory, supported by research, that many alcohol abusers have untreated mental health issues; from outright illness to a sort of “raised by wolves” scenario where they were never given the emotional coping skills to handle adult life.

    THIS, IMHO, is a great use of public dollars, for all kinds of addiction, and it does not require much money compared to one sensational murder trial.

  11. 11
    Face says:

    Sooooo…..those convicted of gun crimes get monitored twice a day to make sure they’re not shooting rounds at targets or humans?

    Ha ha ha! I crack myself up.

  12. 12
    Ex Libris says:

    @Richard Mayhew:

    I’m sure it is being sold that way, and I’m sure that is correct. I’m just imagining trying to set it up in a Randian state like Kansas or the current Wisconsin. When the point of the the government is not to govern, getting anything funded up front, even something as obviously money-saving and useful as this program looks to be, is a struggle. And before long they’ll stop spending money at the other end, too – let all the drunks die off early, and decrease the surplus population …

  13. 13
    Punchy says:

    @Ex Libris: No chance this would ever get set up in KS. The LTEs would read like an Onion article on this….”Invasion of priracy”, “illegal-fying an ostensibly legal consummation”, “Violation of 7th Amendment Rights”, “How can one operate a gun without beer?”….

    Not to mention, Brownback would give special tax privileges to repeat offenders in order to grow their small businesses and destroy their local school district.

  14. 14
    elm says:

    @Eric U.: SD is an exceedingly red state, though not yet terminal like KS.

  15. 15
    Rob in CT says:

    Kleinman has me sold on

    swift/certain/small punishment regimes

    There’s obviously the “is it scaleable?” question, but this stuff makes sense. It should absolutely be tried, and if it works it’s a massive win-win-win (win on outcomes [health or otherwise], win on cost savings, win on freedom [being monitored constantly may suck, but it has to beat being in a cell]).

    If Red States won’t do it (and actually I’m really not sure they wouldn’t), blue states should definitely try it.

  16. 16
    cmorenc says:


    So which Republican votes to kill it first becuz FREEDUMB?

    They’ll kill it for two reasons:
    1) This approach to a public health issue smacks too much of SOCIALISM instead of using harsh punishment to deal with offenders.
    2) The tax cuts necessary for prosperity require budget cuts to discretionary spending programs like this in order to keep budgets balanced.

  17. 17
    gvg says:

    Pity we can’t do it for other drug abuse crimes, but most recreational drugs don’t have reliable tests, or aren’t cheap/easy to test for etc.

  18. 18
    Brachiator says:

    A coworker with a DUI had to have some kind of breathalyzer device installed in his car. He had to use it for 6 months. When he was all done, he drove over to the local bar and had a drink.

  19. 19
    NotMax says:

    Addressing the symptoms and not the disease is always cheaper.

  20. 20
    Geeno says:


    How can one operate a gun without beer?

    That’s the Onion headline right there

  21. 21
    peach flavored shampoo says:

    @Brachiator: Are people with court-ordered breathalyzer devices in their car prohibited from renting a car? Because if not, then I see an (expensive, but since when do alkies care about wasted $ ?) work-around.

  22. 22

    Find this appalling from a civil liberties standpoint.

    From a health/statistical viewpoint, the benefit is staggering. Still wouldn’t support it.

  23. 23
    Brachiator says:

    @peach flavored shampoo:

    Are people with court-ordered breathalyzer devices in their car prohibited from renting a car?

    No idea.

    And things haven’t changed much since I was young and stupid. Many co-workers between age 21 and 30 see drinking as an essential part of their social life, and they accept DUI and suspension of their license as just another rite of passage.

  24. 24
    Calouste says:

    @peach flavored shampoo: Probably not technically prohibited, but I assume car rental companies run some kind of check on your driver license and will deny the rental if something shows up.

    Just checked, my state allows you to check it online and it will show if your license is valid and if you need to have a Breathalyzer as a condition of driving.

  25. 25
    Fair Economist says:

    Total deaths is an underestimate of long-term benefits, because of the reductions in cirrhosis and dementia.

  26. 26
    OzarkHillbilly says:

    These statistics need to be unskewed. No way a gov’t program could ever have a positive effect.

  27. 27
    beltane says:

    @Brachiator: The same exact thing happened with an acquaintance’s father. Immediately after the breathalyzer device was removed from his car he had a few beers and drove off. Being a sad old drunk, he promptly got into an accident.

  28. 28
    jl says:

    When more data becomes available would be interesting to see what incentives are for private insurance to provide similar program, given current retention of enrollees.

    I’m guessing that there is no ‘business case’ for the program and public provision of some kind is required.

  29. 29
    gvg says:

    @CONGRATULATIONS!: Why do you think it’s a civil liberties problem? It’s based on individuals actual actions and there is a trial, with appeals and such.

    Now we know these things can be misused such as the drug laws ending up incarcerating far more blacks than whites….but that can apply to almost any law. What specifically do you mean by appalling civil liberties standpoint? Because I don’t get it. The alternative is to send them to jail, which seems worse to me.

  30. 30
    Xantar says:

    The program only had to avoid two deaths per year or add 120 QALY improvements to be cost effective as a public health measure.

    Where did the 120 QALY number come from?

  31. 31

    @Xantar: Quick back of the envelope calculation on my part. Use $100,000 as a decent guess as to revealed willingness to pay for 1 QALY (Quality Adjusted Life Year) and then do long division.

    That number is fuzzy, but the point is that the needed pay-offs are so low for the cost of the program, they are hard not to achieve.

  32. 32
    Ella in New Mexico says:

    I’m glad there was some effective result in this program, but I don’t see how–in the long run– this is a healthcare success.

    This program is not “healthcare”, it’s law enforcement. And a criminal justice response to a crime involving alcohol does not equal “treatment for addiction”.

    I’ve personally done counseling with these folks in a “12 week educational program” as part of their probation. And as an RN I have the privilege of working in the department that ends up taking care of acutely detoxing alcoholics in my hospital. I’d say the majority have been involved with LE, many completed monitoring programs, attended “educational programs” that were crappy substitutes for therapy and medication, and quite a few spent anywhere from a few nights to years in jail for alcohol related crimes.

    As soon as the monitoring and the punishments and the classes and the threat of imprisonment ended, too many of my patients found the nearest liquor store and began using again.

    That’s because addiction is a deeply rooted, complex health problem and we can’t fix it by telling the person they just can’t drink or use, and expect the mere absence of the substance to cure them. Treatment for addiction only works if you get to the root of the addiction and address it, long term, over time with good therapy and medication, and with good case management to keep the person employed, housed, and fed.

    And that costs money, a whole lotta money. We can find ways to save money, as usual, by doing the right thing up front, early on in the addiction process rather than waiting for the person to become so physically and cognitively damaged cost society a whole lot more.

  33. 33

    @Ella in New Mexico: It is a healthcare success in that it is removing a lot of people from the healthcare system by reducing the number of accidents, the number of injuries and the amount of liver damage incurred among a population that has self-identified as being at risk of causing and incurring injuries and liver damage.

  34. 34

    @Ella in New Mexico: I agree, getting people appropriate care at the point where use has not transitioned into dependency nor abuse is far better than treating further downstream. The 24/7 Sobriety program is already fairly far downstream as it applies to people in the criminal justice system for a subset of reasons, but as a public health intervention, that is upstream of the emergency room.

    So how do we go even further upstream so people don’t hit the criminal justice system?

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