Gambling in the U.S. has never been so accessible. Over the last decade, the growth of the business, both commercial and tribal, has been impressive, with a number of new markets embracing gambling as a way to increase tax revenues.
A few states have welcomed online gambling, while still more sell lottery tickets online.
But while most Americans now view gambling as acceptable for themselves and others, their views about problem gambling and problem gamblers are still quite poor.
“They frequently misunderstand the nature of gambling addiction, seeing it as a symptom of moral weakness rather than a medical condition,” says Keith Whyte, executive director of the National Council on Problem Gambling (NCPG).
Whyte says the council’s own public surveys find considerable skepticism about the effectiveness of treatment and misunderstanding about recovery. This negative public perception is a major reason why government has been reluctant to provide public funds for treatment and research, he says.
It’s a major reason why “people with problems are reluctant to get help,” Whyte says.
While the number of states providing services has grown from 35 in 2006 to 40 last year, and public funding for problem gambling was $71 million, it’s still just a drop in the bucket.
“This is only 22 cents per capita, 341 times less than our per-capita spending on substance abuse, and nobody thinks the substance abuse system is over-funded,” Whyte says.
Whyte describes the level of services and spend as clearly “inadequate,”
especially in the states that do not fund problem gambling programs using a proportion of gaming or lottery revenue.
Those states are Arkansas, Wyoming, Texas, Alabama and South Carolina.
“We believe the national spend should be the equivalent of 1 percent of gaming revenue, or roughly $1.1 billion last year,” Whyte says.
Although there is still no treatment standard, Christine Reilly, senior research director with the National Center for Responsible Gaming (NCRG), says there is more research today demonstrating the effectiveness of treatment strategies such as cognitive-behavioral therapy.
Reilly adds that treatment includes “pharmaceutical interventions such as naltrexone, a drug that seems to blunt the craving for gambling.”
As the U.S. Congress moves forward with its efforts to make changes to or eliminate the Affordable Care Act (ACA), also known as Obamacare, as well as rollbacks in Medicaid funding in coming years, experts say problem gamblers are one of the most vulnerable when it comes to cutbacks.
“We were originally hopeful that the Affordable Care Act—with its emphasis on expanded behavioral care—would help expand coverage for gambling disorders,” Reilly says.
“But it’s been complicated because some states are still following old regulations about not supporting care for impulse-control disorders, a category in which gambling disorders were classified by the Diagnostic and Statistical Manual of Mental Disorders,” she says. “The 2013 change in the DSM-5 reclassifying the gambling disorder as an addiction also gave hope that expanded coverage would ensue.”
“But all is uncertain at this point,” Reilly says.
Whyte agrees, saying the ACA was a big step forward in providing access to behavioral health care, which includes gambling addiction.
The NCPG along with the America Gaming Association, the Association of Gaming Equipment Manufacturers and the National Indian Gaming Association, sent a letter to both the House and Senate urging them to ensure their repeal-and-replace efforts did not set back this progress.
“Unfortunately, the House bill would not only eliminate the behavioral health essential benefit provisions, but would also require states to consider individuals with gambling winnings above $80,000 as ineligible for Medicaid for up to 20 years,” Whyte says.
Whyte and other problem gambling experts note that this provision in the House bill would eliminate health-care coverage for an individual with a serious to potentially life-threatening illness who requires more than $80,000 in medical care.
“Problem gamblers may be one of the most vulnerable populations in America,” Whyte says. “Most private insurers refuse to reimburse for a primary diagnosis of problem gambling, even states that do provide funding don’t always fund treatment… and now problem gamblers who win a jackpot can lose eligibility for the last source of health care.”
Problem gamblers seeking treatment report on average gambling debt twice their annual income, yet they have far higher health-care costs since they are probably the group of Americans least likely to be able to access services for their gambling problem or health care in general.
Public Health and Gambling
When asked about gambling’s impact on the general health of society at large, Whyte and Reilly agree that it is the hidden impact on other diseases and disorders.
Reilly stresses that gambling can have both positive and negative public health benefit.
Positive in that casinos, for example, can lead to economic development and jobs with benefits such as health insurance. Of course, the negative side is gambling disorder, suffered by approximately 1 percent of the adult general population.
“But keep in mind that even though we have seen tremendous expansion in legalized gambling over the past 30 years, the rate of gambling disorder has been stable at 1 percent,” Reilly says. “This indicates that the population has adapted to new gambling opportunities.”
Whyte notes that problem gamblers tend to have higher rates of other problems.
“And that the more disorders you have, the greater severity of problems and higher social costs,” Whyte says. “So the 6 million or so problem gamblers drive up rates of alcohol and drug use, depression, homelessness and suicide.”
And when the co-occurring gambling disorder goes untreated, it leads to higher rates of relapse and transference of problems, according to the NCPG.
For example, many people are aware of the national epidemic of suicide among military personnel and veterans, Whyte says.
“While the issue is extremely complex, we estimate military and veterans have at least twice the rate of gambling problems, and we know approximately 20 percent of people with severe gambling problems make a serious suicide attempt,” Whyte says.
“So while gambling problems may not be a primary cause of the high rate of suicidal behavior in this population, it is likely that it is a contributing factor,” he says.
A hidden gambling addiction that goes undetected and unaddressed might just be enough to push a veteran in the Veterans Administration system already struggling with alcoholism and homelessness or a service member dealing with post-traumatic stress disorder over the edge.
That high rate of gambling addiction in the U.S. military is the driving force behind legislation that would require the U.S. Department of Defense to screen active-duty personnel for potential gambling disorders in both its annual health and behavior surveys.
The legislation, recently introduced by Senator Elizabeth Warren, would implement recommendations in a 2017 report from the Government Accountability Office (GAO), which was initially requested by the Massachusetts Democrat in 2015.
Released in January, the GAO survey found that just 0.03 percent of active service members each year were diagnosed with a gambling disorder or seen for problem gambling in fiscal years 2011 through 2015.
The NCPG believes 57,000 members of the military can be classified as problem gamblers.
Warren’s bill—the Preventing and Treating Gambling Disorder in the Military Act of 2017—describes gambling disorders as an “addiction similar to substance-use disorders, such as those associated with alcohol and drugs.”
She also called problem gambling a “public health concern.”
According to Warren’s legislation, a gambling disorder is a public health concern “characterized by increasing preoccupation with gambling, loss of control, restlessness, or irritability when attempting to stop gambling.”
Problem gambling is also identified by a “continuation of the gambling behavior in spite of mounting serious, negative consequences.”
Gambling disorders are also associated with a higher risk of suicide attempts, substance-use disorders and other mental-health conditions.
Reilly adds African-Americans and young adults to the list of at-risk populations. She says increased screening for the disorder among these populations is a priority.
Also, Reilly supports expanding prevention efforts that target these groups to include gambling as well as substance use.
“African-Americans and military veterans are at risk because they have higher than average health problems compared with the general population,” Reilly says. “Co-occurring psychiatric disorders are the biggest factor in making someone vulnerable to a gambling disorder.”
Reilly cautions that emerging adults, age 18 to 25, are at risk because of higher rates of impulsivity and increased opportunities to gamble.
Millennials don’t gamble. Not as much as their parents or grandparents, anyway.
But the reluctance of younger gamblers to sit for hours at a slot machine or a blackjack table in a casino has not led to a decrease in the incidence of compulsive gambling.
Born in 1980 and after, this generation grew up with technology and instant communication being an integral part of their lives.
Instead of traditional gambling, millennials do play real-money fantasy sports, eSports, sports betting and in-play betting on sports, and social games like Candy Crush on their smartphones or tablets.
“They are often played as a social activity,” according to Nelson Rose, a professor with Whittier Law School, who describes the generation as “avid consumers, eager to spend money, willing and eager to take risks.”
In an article titled “The Next Generation of Compulsive Gamblers,” Rose asserts that millennials’ preferences have increased their risk of becoming addicted, and “not to games we all recognize as gambling.”
As for real-money, daily fantasy sports, Rose argues games like DFS and in-play betting on sports events are perfect for millennials who follow sports.
“They often are played as a social activity,” Rose wrote. “The outcomes are known quickly. And, whether or not DFS is gambling, it appears the games can be beaten by skillful play.
“This characteristic of both the games and younger players make games with some skill more dangerous than pure chance games like lotteries or roulette. A sports book operator told me that he was gearing his operation toward millennials, because younger bettors think they know more than they actually do, and are so self-confident that they are willing and even anxious to put money on their decisions.”
Millennials do not realize that there are a small number of professionals, both big bettors and operators, who spend hours each day calculating the true odds to beat these quasi-amateurs.
Rose also emphasized millennials’ distrust of cash, preferring to use credit or debit cards or non-cash alternatives.
“Completely cashless gambling, with an element of skill and lots of time to take breaks, is going to create a whole new generation of problem gamblers,” Rose warned.
“But it is important to note that the millennials who become addicted to games are just as likely to run into problems on skill contests, free games and other electronic pastimes that are legally not gambling at all,” Rose wrote.
But only time will tell if Rose’s expectations are true that new forms of gambling will increase addiction.
Problem gambling experts believe history has shown that problem gambling prevalence rates remain relatively stable over time despite the introduction of new technology or even increased gambling opportunities.
“It certainly does appear that this younger generation is consumed by anything on that little screen that seems to be constantly before their eyes—sometimes referred to as online addiction,” says Connie Jones, director of responsible gaming with the Association of Gaming Equipment Manufacturers (AGEM).
Jones says the internet is merely a vehicle for delivery of many potentially addictive behaviors such as pornography, shopping, social media and non-gambling games.
“I believe this generation is very savvy on how they spend their money, and data has shown that they enjoy playing ‘for-fun’ casino games as much as or more than those for real money,” Jones says.
Responsible gaming tools such as problem gambling awareness, setting limits, self-exclusion and information for help with a gambling problem are much easier to implement for online gambling games than in a brick-and-mortar venue, she says.
“Counseling services are even available online,” Jones says. “Never in the history of gambling have there been as many player protection measures available to gamblers.”
In the state of Massachusetts, Play My Way, the responsible gaming limit-setting tool, has received positive reviews, she says. These types of features on games are common in other countries, and have just recently entered the United States.
As of June 30, more than 12,670 players had enrolled in the Play My Way program, according to the Massachusetts Gaming Commission. The program is one of several tools in the state’s wide-ranging responsible gaming program known as GameSense.
“New and/or expanded gaming programs now consider addressing problem gambling as a priority in the initial phases of program creation, (including) Japan,” Jones says. “In the very recent past, I recall problem gambling was often a last-minute consideration for new gambling programs.”
Jones says she believes the gaming industry is making giant strides in protecting consumers.
Not Playing the Game
MGM Resorts seeks to expand the GameSense program developed in British Columbia
MGM Resorts International is rolling out a unique responsible gaming program called GameSense in its U.S. casinos by the end of the year, which puts trained counselors in casinos to inform customers about the dangers of gambling.
Commercial gambling revenue in the U.S. totaled more than $39.1 billion in 2016, according to data compiled by the University of Nevada, Las Vegas Center for Gaming Research.
Problem gambling affects some 7 million Americans, the National Council on Problem Gambling reports.
GameSense encourages players to adopt behaviors that can reduce the risk of developing gambling disorders. Some of those behaviors are setting time and money limits, and having an open dialogue with friends and family about personal gambling habits.
The program will have a presence at MGM Grand, Bellagio and Borgata in Atlantic City, through GameSense information centers, where trained counselors can explain why gambling is a game of chance and debunk myths like lucky numbers or a “hot” slot machine.
On its website, GameSense recommends visitors play for fun, not to make money; don’t chase losses, accept them as the cost of entertainment; and balance gambling with other types of leisure activities.
“Our vision for GameSense is to transform the guest experience at our properties by providing a program that is rooted in enhanced customer service, player education and leading research,” says Alan Feldman, MGM’s executive vice president of global industry affairs.
Until now, the only help for compulsive gamblers in a casino was a pamphlet called “When the Fun Stops,” and a toll-free number, 800-522-4700.
For GameSense, MGM has partnered with British Columbia Lottery Corp. (BCLC), which operates 35 casinos plus bingo halls and the provincial lottery in British Columbia, Canada.
BCLC created the program in the mid-2000s, and it’s not only part of the province’s lottery, but also casino gaming and sports betting.
The program is also used by the Connecticut Lottery, the Massachusetts Gaming Commission, and Canadian provinces Alberta, Saskatchewan and Manitoba.
In Massachusetts, Play My Way is another part of a responsible gaming program under GameSense.
Play My Way is a voluntary program that alerts gamblers when they are approaching their self-imposed limits for losing money. In just over a year, some 13,000 people have signed up for the program at Plainridge Park Casino in Massachusetts.
MGM will offer the program at its casino in downtown Springfield, which is scheduled to open next year. Wynn Resorts’ $2.4 billion Wynn Boston Harbor is also expected to offer GameSense when it opens in 2019.
The system was designed to allow gamblers to set a limit on how much they are willing to lose. Warnings pop up on slot machines telling a gambler when he or she is approaching the limit, at the limit and exceeding the limit.
It does not stop gamblers from playing.
Mark Vander Linden, Massachusetts Gaming Commission’s director of research and responsible gaming, says he was encouraged by the early indications of player interest. The commission has contracted with the Cambridge Health Alliance to evaluate the program to determine its overall effectiveness.
Keith Whyte, executive director for the National Council on Problem Gambling (NCPG), praises the efforts in Massachusetts to create a program to help consumers gamble responsibility.
But, Whyte says the NCPG is still waiting for the evaluation. He says it is always tough “to evaluate a preventative and educational tool like GameSense.
“The big challenge right now is not responsible gaming tools; it is making sure there is a robust problem gambling system underneath so that when a casino player picks up a brochure, or a lottery winner calls the number on the ticket, they actually get help,” Whyte says.
MGM will donate $1 million over five years to the International Gaming Institute at the University of Nevada, Las Vegas, which will research the program’s findings to improve it and aid similar efforts.