Chris Christie has been getting a lot of (well-deserved) attention for a speech he gave recently about addiction, and it’s easy to imagine looking back at this as a turning point in his campaign, like those featured in Slate’s Whistlestop podcast. I think there’s a lot to applaud here, but I think we have to recognize that it is an immensely complicated issue.

First, even many of us who recognize that addiction is a disease fail to think of it that way. I have two friends who died recently. We lost one to multiple myeloma and the other to liver failure that was very likely a result of too much drinking. Although anybody who knows me and reads this will likely know who I’m talking about, I’m going to call them TJ and RR to make me feel a little more comfortable talking about them without their permission. Most people who knew them both were very sad to hear that they died, and their deaths coming within days of each other hit many of us especially hard. Among those who knew them both very well, there were a few who had very interesting (to put it kindly and diplomatically) responses. More than one pointed out how much time, energy, and money was spent  trying, and failing, to help RR, and that it was hard to feel sympathy for him because he kept drinking in spite of it all. But TJ got excellent medical care for his multiple myeloma. Costly, time-consuming medical treatment. Why don’t we see this as the same. RR got medical treatment for a disease, and that medical treatment was unsuccessful and he died. TJ got medical treatment for a disease, and that medical treatment was unsuccessful and he died. Both are very sad, yet there was near universal sympathy for TJ, who people recognized was the victim of a cancer that was no fault of his own, while that recognition wasn’t universal for the disease that took RR’s life.

I realize that the issue is immensely complicated, and that cancer and treatment of it often has nothing to do with the behavior of the patient (aside from compliance with the treatment, but non-compliance isn’t a feature of the cancer). It’s easy to say that the person with a substance use disorder makes a choice to use the drug, and if they chose differently, the problem would go away. I also recognize that thinking of substance use disorders as unrelated to choice challenges our view of free will. We like to think that we’re in control of our lives. We like to think that if we avoid bad places, we’ll be safe. When bad things happen, we like to point to something we think we can control that makes us think that bad thing couldn’t happen to us. We hear about the kid abused by a police officer in a classroom and we say, “my kid would never talk back to a cop, so that wouldn’t happen to our family.” We hear about the kid who killed his brother with his dad’s gun and we say, “I always keep my guns locked up, so that would never happen in my house.” We point to things that we could do differently, using our free will, that protects us from the bad things that could happen.

There is a very good chance that anybody reading this knows somebody who is actively addicted to drugs (and by “drugs” I include alcohol and nicotine, and exclude caffeine…which is probably fair) or who was once addicted to drugs. Those who fall into the “once addicted to drugs” category are exceptions. Treating those who suffer from substance use disorders is incredibly expensive, and by many people’s view, is often not successful. The National Institute on Drug Abuse (part of the National Institutes of Health) has been working to change these views. They point out that many chronic diseases require ongoing treatment, and that relapses are common in other diseases like diabetes and hypertension. When an alcoholic stops going to AA meetings and starts drinking again, we consider his treatment to have failed, but we don’t consider it a treatment failure when somebody stops taking their prescription and their hypertension returns, or even when the medicine needs to be adjusted in dose or type. The diseases aren’t considered equal.

The difference shows up in health insurance coverage also. When somebody has cancer, for example, even if the prognosis is very poor, there is often insurance coverage for ongoing treatment. Treatment for substance use disorder is far less common, especially for ongoing treatment. A recent report found that in 2013, 82% of people who needed treatment for substance use disorder were untreated. Part of this is because many with the disorder do not seek treatment, believing that they do not need treatment, but many were unable to get treatment because of lack of coverage. Christie may have found lots of support for the substance of his speech, but is he willing to put his money where his mouth is? The Affordable Care Act (Obamacare) took great strides to include substance use disorders as a key part of health benefits and made it law that insurance plans sold on the exchanges and provided by Medicaid have to include services for substance use disorders. This provision was incredibly important because without this government action, coverage for substance abuse disorders was woefully inadequate except from the more expensive health care plans. I wonder how Chris Christie feels about that.

Maybe somebody will challenge him on this issue. They might want to ask him about what New Jersey has done for mental health care in general. They might want to ask him about how his state has dealt with the issue. The answer might make him look like somebody who says he cares….but doesn’t care as much as he wants us to think he does.