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About Mental Health

LOOK AT A map of states president-elect Donald Trump won in November alongside a map of states with the highest rates of opioid prescriptions, and you’ll see they mostly overlap. Look more closely at the data, as one Penn State professor recently did, and you’ll find that Trump outperformed his Republican predecessor Mitt Romney the most in counties where opiate and suicide mortality rates are highest.

It’s little wonder, then, that mental health and substance abuse issues have become a key talking point for Trump, who has promised to crack down on drug cartels and called America’s mass shootings an issue of mental health—not guns.

He’s not the only Republican to adopt behavioral health as a priority. House Speaker Paul Ryan pushed for mental health legislation in the wake of the San Bernardino shooting. Senate Majority Leader Mitch McConnell, whose home state of Kentucky is a leader in opioid deaths, recently penned an op-ed titled “More Must Be Done on Heroin – soon.” And the Republican-authored 21st Century Cures Act, signed into law in December, will set aside $1 billion over two years to fight opioid abuse.

And yet, late last week, Senate and House Republicans set in motion the first steps of a plan that researchers warn could cut mental health and substance abuse treatment off at the knees: the repeal of Obamacare.

“I don’t think there’s anyone in the mental health community who thinks withdrawing the Affordable Care Act would be good for behavioral health,” says Sherry Glied, dean of New York University’s Robert F. Wagner Graduate School of Public Service, who advised the George H.W. Bush, Clinton, and Obama administrations on health policy. “It’s hard to even conceive of how that would be true.”

Mouse v. Elephant

Under the Affordable Care Act, all insurance plans sold on the exchange must include mental health, substance abuse, and behavioral health coverage as one of ten “essential benefits.” The legislation also made it impossible for insurers to deny people with pre-existing conditions, enabled young adults to stay on their parents’ plans until the age of 26, and provided mental health parity to people through the expansion of Medicaid in the states. Taken together, these changes have created a watershed moment for both behavioral providers and the people who need their services.

A recent CDC report shows that the percentage of adults with serious psychological distress who are uninsured has dropped from 28.1 percent in 2012 to 19.5 percent in the first nine months of 2015. Other studies have shown a spike in mental health treatment, particularly among young adults. Perhaps counterintuitively, researchers welcome those spikes, because of the persistent treatment gap that often keeps people from getting help, even when they have coverage.

Researchers fear that repealing Obamacare could undercut that progress, without a plan to protect people with pre-existing conditions and mandate mental health and substance abuse coverage. According to Richard Frank, health economist at Harvard Medical School, approximately 1.8 million of the 21 million people covered under the ACA are currently receiving mental health services and subsidies. That amounts to approximately $5.5 billion in coverage, he estimates—coverage that would disappear if Obamacare were repealed.

All of this, experts say, makes the much-celebrated Cures Act look tiny and ineffectual by comparison. That bill, which covers a range of health and research related issues from cancer research to a precision medicine initiative, includes just $1 billion in grants to be doled out over two years for drug addiction and treatment programs. “The Cures Act is great, but the amount of money in the Cures Act for mental health, compared to the ACA is like a mouse and an elephant,” says Glied.

Tip of the Iceberg

It’s not just the loss of billions of dollars in coverage that is problematic. By pushing legislation that funds programs for people already seeking treatment, members of Congress seem to believe that opioid abuse and mental health issues can be addressed with targeted interventions. That kind of thinking assumes that people with mental health and substance abuse issues belong to some self-contained, finite group. “The reality is, everybody is at risk of mental health problems,” says Glied.

That’s been one of the biggest challenges in closing the so-called treatment gap: People who have coverage don’t seek treatment, either because of stigma or because they don’t think they need it. “People’s primary care providers are often the first point of care for mental health treatment,” says Brendan Saloner, assistant professor of health policy at Johns Hopkins University’s Bloomberg School of Public Health. “Just getting people into the doctor’s office can be a really important tool.”

That’s especially true of people with substance abuse issues, Glied says. “To have a special program for opioids is fine if you know a person’s problem is opioids,” she says. “But what about a person who says their problem is chronic pain, and they need to keep increasing their painkillers, but they don’t think of themselves as opioid users? There’s a real challenge there.”

Without broad-based coverage, these types of cases become harder to detect.

Silver Lining

It’s still unclear what exactly Republicans in Congress and Trump have in mind in terms of a replacement plan. While some have warned that such a replacement would take time, in his press conference this week, the president-elect promised the introduction of a new plan would happen “essentially simultaneously.”

But people like Glied are heartened—if ever so slightly—by plans floated by the likes of Speaker Ryan that include provisions for so-called “continuous coverage.” That means people who have coverage and keep it will be protected from insurance price gouging and rejection, even if they have pre-existing conditions.

“Bizarrely enough, even though the whole system may be falling apart, this is the moment to get covered,” Glied says.

Others, like Saloner, are placing their faith in red state governments that will likely bear the financial burden of a repeal, as state and local hospitals become the final safety net for people with mental health and substance abuse issues. “Those voices can have some influence on federal policy,” says Saloner.

Already, Gov. John Kasich, whose home state of Ohio has been plagued by opioid deaths, has been doing just that. Speaking to reporters Wednesday, he cautioned against repealing the legislation, asking, “What happens to drug treatment? What happens to mental health counseling?”

The answer may be hard for the president-elect and Republicans in Congress to square with their promises to address these mental health crises, once and for all.

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