It is no secret that mental health conditions are highly prevalent both in the United States and across the globe, and recent years have seen an increase in the dialogue on the causes and consequences that we face. The discussion of mental health and addiction has been amplified on the context of discussing the opioid epidemic and the need for better treatment options. However, we do ourselves a disservice when discussing mental health outside the context of the broader healthcare system in which care is provided, and the insurance constraints that drive shortcomings in healthcare delivery.

​The Substance Abuse and Mental Health Services Administration (SAMHSA) estimated that 58% of the adult population has a medical condition and that 25% of the adult population has a mental health condition. But at least as important is the rate of comorbidity that they estimate: 29% pf those with medical conditions have mental health conditions, and 68% of those with mental health conditions have medical conditions. Indeed, they find, those who have been diagnosed with asthma were 2.3 times more likely than others to screen positive for depression, and those with cardiovascular disease were 1.43 times more likely to have an anxiety disorder.
 
They estimate further that not only is there substantial overlap between these patient populations, but one may be a risk factor for the other. While 5% of the population without chronic medical conditions experiences major depression, the rate increases to 8% among those with one medical condition, 10% among those with two conditions, and 12% among those with three or more conditions. It is worth emphasizing that this is a nontrivial subset of the population – indeed, approximately 31.5% of American adults (and 49% of those ages 45-64) live with multiple chronic conditions, and 71% of American healthcare spending goes toward those individuals. These rates of multiple chronic conditions is  higher for women than for men, with women also more likely to experience depression.
 
That chronic illness (or chronic pain) would be deemed a risk factor for depression is hardly surprising. Not feeling physically well can make it difficult to be in a good frame of mind. Moreover, chronic illnesses may be of a sort that can be treated but not cured, thus potentially causing changes of lifestyle and perhaps a sense of hopelessness about improvement. Moreover, medical bills and associated stressors (more medical tests, appointments, coordination of care among physicians) can produce financial strain and in turn anxiety and/or depression. That mental health conditions could contribute to worse physical health is also unsurprising considering the potentially worsened habits with respect to diet, sleep, and exercise, and may be less vigilant in treating chronic physical conditions (e.g., may become lax about medication management). The mental and the physical are inherently interactive.
 
The interactive nature of the two should be all the more reason to better integrated system of treatment than the United States currently offers. The problem is that it is much easer to obtain insurance coverage for medical than for mental health conditions, with only 55% of psychiatrists accepting insurance, compared with 93% of other medical providers accepting insurance and 86% accepting Medicare. What’s more, those who do accept insurance may accept a limited number of insurance patients or may have schedules that are full given the high demand and limited supply. This creates a system in which obtaining psychiatric treatment can in some cases become a luxury, despite the fact that those who are lower income are more likely to report depression. Indeed, 31% of those in poverty say that they have been diagnosed with depression at some point, compared with a rate of 15.8% among those who are not impoverished. Such individuals will be unable to go out-of-network as is often required of those seeking mental health treatment, and may even be unable to accord the various medical treatments that may be required for their chronic physical conditions. Failure to address one set of conditions can exacerbate or at least leave untended the other concerns.  
 
And getting an in-network provider is just the first step. Services also need to be covered by the insurance company, and despite Congress’s 2008 passage of the Mental Health Parity and Addiction Equity Act, requiring that treatment coverage be equal for physical and mental health, the legislation remains poorly enforced, with insurance denials of 14% for physical health and 29% for mental health and insurance company challenges of “medical necessity,” and 25% of health plans were found inconsistent with the legislation.   
 
Psychiatrists and other medical professionals are aware of the problems in treatment that pervade our healthcare system. Absent good medical care, one risks the exacerbation of both physical conditions and risk factors for mood and anxiety disorders. Absent good mental health care, one makes oneself more vulnerable to poorly managed physical health, regardless of preexisting conditions.
 
Yet for a private practice psychiatrist to take insurance is far from a costless enterprise, requiring the setting of a rate that insurance companies accept, marked paperwork of determining fees, collecting copayments while submitting for reimbursement and waiting for those fees to be processed, and challenging any insurance claims denials. This amount of paperwork can require the hiring of a secretary, which is an additional financial burden requiring even more profit. Given the needs to manage this paperwork, it comes as little surprise that the practitioners least likely to accept insurance are those operating in solo practices.  Further, reimbursement rates for psychotherapy are low, thus disincentivizing in-network providers from doing anything other than brief medication appointments in order to stay afloat. This is particularly unfortunate given the reality that combining medication management and psychotherapy is the best treatment for depression compared with either treatment alone. Indeed, among those depressed patients receiving both medication and psychotherapy, 72% in a 2004 study achieved symptom remission compared with 57% of those receiving only medication management.
 
It is difficult to begrudge psychiatrists from responding to financial incentives. The average medical school debt is $180,723, in addition to which physician salaries overall are actually declining. Getting out of debt is a more than reasonable expectation, as is a monetary reward for the hard work of medicine. The problem, rather, is in the incentives that insurance companies create in structuring lower reimbursement rates for psychotherapy augmenting pharmacological treatments.
 
Raising reimbursement rates to physicians is not something that is at all profitable to insurance companies, which have already in many cases reported losses in recent years in the aftermath of the Affordable Care Act, with insurers losing money in 41 states in 2014. Insurance companies are for-profit and thus by definition are not in the business of providing charity or even operating at cost, but rather employ strategies to reap financial gains. The problem, though, is that public health and economics don’t always have incentives that are aligned – in fact, short term incentives are often not. Band-aid solutions are easier and may be cheaper in the short-term (though may yield greater long-term costs due to ineffective treatments). Effective public health interventions are expensive and require both financial and policy commitments to change irrespective of insurer profits.
 
The reality is that effective mental health treatment is economically beneficial in the long run, albeit not necessarily the short term. Early interventions can obviate the need for more expensive medications and hospitalization. Major depression is the leading cause of disability in the United States among 15-44 year-olds, thus yielding lower economic productivity and the drawing on government resources in the form of disability and Medicaid. And as discussed above, it can potentially reduce the exacerbation of other physical conditions that are costly to treat. Reducing the future need for expensive treatment might best be averted through effective treatment in the present, ideally proactively, though this is not a model that is particularly consistent with the profit motives of the current American healthcare system.
 
The other reality is that politics is incremental. Sanders’ Medicare for All health plan is by far the most leftward turn that has been proposed at a national level, particularly given the vigilance with which members of the Republican Party have fought the Affordable Care Act, with the 2016 GOP platform declaring a commitment to the ACA’s repeal. Given the frequency of divided government and the extent of polarization on this subject, expanding Medicare to all Americans was not a policy that would have garnered nearly adequate support even with the fact that diseases from diabetes to depression affect Democrats and Republicans alike. For all its politicization in Washington DC, health is (or should be) fundamentally a human and not a political issue. Clinton’s plan expands on the progress of the ACA within the confines of the political reality in which she operates – that is, maintaining the existing healthcare apparatus but working to curb out-of-pocket costs and prescription drug prices, and incentivizing the rest of the United States to adopt Medicaid expansions to help low-income Americans.
 
This will do much to address the fact that 31 million Americans have underinsurance, with many facing high deductibles and other out-of-pocket costs. However, it will not address the reality that insurers’ profit motives are not conducive to supporting some key evidence-based medicine. Having government insurance plans provide better mental health coverage will be an essential move, and the importance of emotional wellbeing thankfully has been addressed squarely by the Obama Administration in general and the Surgeon General in particular. So what are some other options?

​Pushing insurance companies to better streamline claims processing to reduce the paperwork burdens of physicians’ insurance participation might at least make less daunting the prospect of operating a solo or small practice with insurance clients given paperwork burdens that are currently pervasive. Finding ways to provide government financial incentives (potentially tax breaks) to companies to make healthcare more accessible – both in the form of physician and patient reimbursements – would be an additional option to broadening access to care. This will be particularly valuable in the case of psychiatrists' reimbursement for psychotherapy so as to better facilitate evidence-based mental health care. Increasing forgiveness of medical school loans based on the share of low- and middle-income as opposed to private-pay patients will be another way to reduce the extent to which physicians’ financial needs drive the type of care that they are capable of providing their patients. Such an approach would be in line with current plans that incentivize working in underserved areas, and could make it more feasible to take on patients relying on plans that may or may not reimburse doctors at as high rates (and certainly providing less lucrative work than private-pay) but whose physical and mental health struggles must be treated. 
 
When you enter an emergency room, you see signs that you are entitled to receive medical care regardless of insurance status or ability to pay. Doctors provide the medical care that they know to be needed, whether the patient is a Democrat or Republican, a criminal or the victim of a crime, poorly or highly-educated. In a world in which politics too often trumps policy, our healthcare system needs to do a better job of facilitating medical decisions that deliver the best quality care to the broadest reach of the population.  

Republican presumptive nominee Donald Trump has made a consistent habit of calling Democratic presumptive nominee Secretary Hillary Clinton "crooked" and "lyin,'" though as with much of American elections, there is more rhetoric than substantive backing. Fortunately, the website PolitiFact does research the candidates' (and others') statements to determine whether they are more truthful or "truthiness" or flat-out "pants on fire."

They categorize statements into six different groups: true, mostly true, half true, mostly false, false, or pants on fire. Aggregating for the presidential candidates and other prominent contemporary figures (Obama, Biden, McConnell, Reid, Ryan, Pelosi) the share of statements rated as some degree of false (that is, the sum of mostly false, false, and pants on fire), I compared the candidates in the graph below. 

It is worth emphasizing that none of the people below are entirely innocent. Indeed, the lowest share of false statements is 23% (by Martin O'Malley), and among those who remained prominent on the political stage, Obama is at 26%, Clinton at 27%, and Sanders is at 29%. But that's all to say that a good outcome is to have no more than a quarter to a third of political statements be inaccurate. Surely we can (or should) do better than that. 

What is perhaps more striking is the other end of the spectrum, at which one finds Ben Carson (82%) and Donald Trump (76%), though Carson's rank is not as reliably scored given the far fewer number of fact-checked statements (such is true of those who dropped out of contention early). The more serious presidential hopefuls who  challenged Trump to the nomination and garnered delegates were also found to have made a number of inaccurate statements, with 65% of Ted Cruz's statements some degree of false, while 41% of Rubio's comments were rated as such, as were 33% of Kasich's. 

There also appears to be some variation across issue areas in the extent to which we see honest reporting (see below). While the extent of false statements is relatively lower in the domains of housing (36%), the economy (37%), and civil rights  and education (tied at 38%), it is quite a bit higher within the domains of gay and lesbian rights (50%), immigration (51%), unions (52%), and health care (54%). (Ironically, 46% of the statements concerning ethics were rated as some degree of false). The high prevalence of the issues of LBGT rights, immigration, and healthcare in this election season gives ample reason to be concerned as to the quality of reporting from the candidates and their surrogates. 

The reality of political campaigns is that things are fast-paced, which can hinder having a great degree of care with respect to campaign statements and the like. Moreover, political spin with respect to one's own (or one's party's) successes or the shortcomings of the opposition can lead in many cases to some degree of misleading. However, for the sake of the integrity of the American election process, we should hold our candidates accountable and compel better accuracy in the statements made at events and on television. After all, ordinary Americans are not the ones spending hours on PolitiFact determining to what extent allegations regarding refugees or foreign affairs or job growth are indeed accurate, particularly when the issues being debated are crucial to securing votes. Moreover, if Trump is going to continue to call others lyin', he should do a better job of addressing first the "truthiness" of his own record.  

​Justice Ruth Bader Ginsburg has been under extensive scrutiny recently for some comments that she made that were highly critical of Republican presidential candidate Donald Trump. Among her comments was, “I can’t imagine what this place would be – I can’t imagine what the country would be – with Donald Trump as president… For the country, it could be four years. For the Court, it could be – I don’t want to contemplate that,” and she joked about wanting to move to New Zealand in the event of facing a Trump Administration. She went on to say that Trump is a “faker” who lacks consistency in his political views and who “says whatever comes into his head at the moment. He really has an ego…”
 
Donald Trump fired back, holding, “I think it’s highly inappropriate that a United States Supreme Court judge gets involved in a political campaign, frankly… I think it’s a disgrace to the court and I think she should apologize to the court. I couldn’t believe it when I saw it.” He then tweeted that she had disgraced the Court and should resign because her “mind is shot.”
 
Apart from the semantic problem of Ginsburg and other members of the Supreme Court being justices and not judges, it is perfectly fair for Trump to be upset. He is not the only one who has expressed outrage or at minimum dismay over Justice Ginsburg voicing loudly and clearly her opinion on the 2016 presidential election.
 
I am not convinced that it was wise for her to have made those comments, but the response seems to me to be overblown given that it does not present any legal conflicts of interest (nor does it reveal any preferences that we did not already know to be underlying, as Ginsburg has been one of the staunch liberals on the Court since her appointment by President Clinton), and absent a problem with the law, the objections are theoretical and not practical problems. 
 
While we sometimes like to think of the Supreme Court as the legal rather than political branch, we often find in practice that it is difficult to divorce law and politics: two equally intelligent legal scholars can see very different things in the Commerce Clause, the implications of which impact whether we have civil rights protections, just as they can reach different interpretations of whether affirmative action constitutes discrimination (a word left undefined in the Civil Rights Act of 1964), and in seeking new jurists, politicians are far from apolitical even when purportedly focusing on the law. There are, in these actors nominated by the president and confirmed by the Senate, inherent issues of politics that we just don't always seen as transparently as in these recent comments.

People have ideas as to the normative desirability of the Supreme Court (and courts more generally) being comprised of dedicated judges who are being neutral arbiters amid complex legal challenges, in contrast with the obviously politicized legislative and executive branches. Indeed, Chief Justice John Roberts characterized his own job as that of a neutral umpire calling balls and strikes, rather than pitching or batting, which is not to say that that comment did not result in some measure of challenge. The reality, which we have seen in the confirmation hearings (or lack thereof) to fill the late Justice Scalia’s seat, is that the Supreme Court is indeed highly political, a fact in the absence of which the President would not so characteristically nominate judges who are ideological allies and the Senate would not prevent hearings because of political opposition to the sitting president.
 
The fact of the matter is, Justice Ginsburg here voiced a preference that was hardly surprising.  Indeed, the only justice for whom the voicing of a political opinion on Donald Trump would present genuinely new information would be Justice Kennedy (and maybe Chief Justice Roberts, though he is a reliable conservative), and if the issue with Ginsburg’s comments are of the law and the proper role of the Court in the political process, then obviously we would need to hold all of the justices to the same standard. More important is the question of whether these comments compromise her integrity to the law as a Supreme Court justice. I do not believe that they do, with the potential caveat that she might be called upon to recuse herself should Trump be personally a party to a lawsuit before the Court.
 
The Supreme Court has gotten involved in far more controversial and legally “squishy” issues, from Justice Scalia hunting with then-Vice President Dick Cheney within three weeks of granting cert to Cheney’s appeal pertaining to the Bush Administration’s energy task force, to the notorious Bush v. Gore (2000), about which former Justice O’Connor has since expressed regrets because it it “stirred up the public” and “gave the Court a less than perfect reputation.” Somewhat more superficially, people from both sides of the aisle responded pointedly to Justice Alito’s visible opposition (shaking his head and muttering “Not true, not true”) to comments that President Obama made of the Supreme Court’s Citizens United v. FEC decision during his 2010 State of the Union address, with Senator Hatch characterizing the response as “rude” and Senator Feingold calling it “inappropriate” for Justice Alito have done so. (In fairness, legal and political science scholars were surprised by both the president’s calling out the Supreme Court specifically, as well as Justice Alito’s response to the charges). And of course, the Supreme Court has involved itself in a number of hot-button issues (e.g., abortion, affirmative action, healthcare, immigration) that heighten partisan divisions among the parties. While we like the idea of a more apolitical (relative to the other branches) judiciary, it is not a notion that is well supported in recent years, and the high numbers of 5-4 splits along party lines only reinforce that.
 
Perhaps there should be a rule (not a legal, but rather simply a more practical and normative rule) that justices should not involve themselves in any way in a presidential campaign outside the strict context of legal challenges brought before them, and for which at least four justices must agree to grant cert. Additionally, unlike the race-based challenge that Trump made with respect to US District Judge Gonzalo Curiel, it may be altogether fair to argue that given personal challenges to Donald Trump (as opposed to voicing a generally liberal ideology in opposition to the preferences that Trump is expressing in his campaign), she might be persuaded to recuse herself in the event that the Court is judging him personally, as opposed to a Trump Administration more broadly defined should he be elected in November. But until that happens, the opposition to Ginsburg seems to be rooted not in the law (she did not break any laws and has not compromised her judicial integrity with respect to any pending cases), but in a rather unrealistic (though perhaps nice) normative desirability that Supreme Court justices stay out of elections and other salient current events. The reality, whether we like it or not, is that we have seen far more egregious involvements by the Court, and what we witnessed was an outspokenly liberal ("notorious RBG") speaking her mind about the election, outside the context of a specific case in which she is acting in her capacity as Supreme Court justice. It may not have been wise for Justice Ginsburg to have made those comments – perhaps she should have risen above it, particularly given her current position on the Court – and it is unclear who “wins” as a consequence of those statements (other than those enjoying a nice Twitter war), but it is not necessarily “wrong” (certainly not from a legal perspective) for her to have done so.  

​It is common practice across the nation to update voter rolls to account for people moving or becoming deceased, though only a handful of states engage in voter purging on the grounds of inactivity. Ohio is one such state that purges from its voter rolls those who have not voted in recent elections, which they define as having missed the prior three consecutive federal elections.
 
On the one hand, if people do not express an intent to vote, it may at first blush seem not to impose a harm. However, if they do choose later to vote and realize that they are no longer registered (as occurred in the context of a marijuana initiative in November 2015), they are then disenfranchised. What’s more, voters are struck from the rolls in Democrat-leaning regions of the state (often poorer and with higher percentages of minorities) at approximately double the rate as are voters in Republican-leaning regions, though it is worth emphasizing that both Democratic and Republican officials have purged inactive voters over the years.  
 
States have across the nation enacted or sought to enact a number of new restrictions with respect to voter registration and casting votes, with at least 180 restrictive voting bills introduced in 41 states in 2011 and 2012 alone. The Brennan Center reports that as of March 25, 2016, though 422 bills were introduced to enhance voting access, at least 77 bills to restrict access had been introduced in 28 states, largely emphasizing photo identification. The voting laws being enacted in various states (e.g., Texas, North Carolina) tend to be centered around discussions as to voter fraud versus voter suppression. Those putting forth arguments pertaining to voting fraud tend to emphasize maintaining the integrity of the election process so that people are not casting votes when they are not entitled to do so, whether because they do not live there, have been disenfranchised due to ex-offender status, or have already voted. Those on the other end of the spectrum call attention to the infrequency of actual voter fraud incidents – with one comprehensive investigation finding only 31 cases of voter fraud in one billion votes cast – along with the disproportionate burden that voter ID laws have on minorities and the poor, as well as the limited incentive to commit the felony of fraud given the virtual impossibility of casting a decisive vote.
 
The Brennan Center for Justice reported that as of the 2006 election, 416,744 voters (5.3% of the total registrants) in Ohio were deleted from the rolls in 2006. The distribution of voter purging across counties and over time is highly varied, they report, with 20,353 removed from the rolls of Franklin County between 1998-99 and 170,000 removed from the rolls of Cuyahoga County in 2001-02. For perspective, these are the Democratic strongholds of the state, with Franklin County containing Columbus and a total of 1.212 million people and Cuyahoga County containing Cleveland and a total of 1.263 million people.
 
Ohio is one of the main battleground states in American elections, having voted for President Obama in 2008 and 2012 but with George W. Bush garnering 118,775 votes more than did John Kerry in 2004 (out of 5,625,613 votes cast in the state), with the state ultimately determining the election. For those of you not keen on math, that is less than a third (28.5%) the number of people purged from the Ohio rolls in 2006. While some of the voter purging may well have been justified on the grounds of change of address or other factors making the individual no longer eligible to vote in that region, a nontrivial number were purged due to inactivity.
 
While Ohio Secretary of State John Husted says that this policy helps to keep lists current, one has to wonder what the actual cost is to having a longer voting list in the system, given that states are already checking for change of address and death. If lawfully registered, the cost of keeping on the rolls those who are not frequent voters is having a longer list in the system, meaning voter information guides are being sent to people who may or may not care, and poll workers may need to sort through more names on Election Day to find those seeking to vote. The benefit is preserving the constitutional right to vote for those entitled to do so, and at a more cynical level, avoiding the bad PR that comes with disproportionately reducing the voter registration of the poor and minorities.
 
Husted argues that if voting is so important to an individual, it would be reflected in their past voting behavior: “If this is a really important thing to you in your life, voting, you probably would have done so within a six-year period.” It is on this basis that Ohio is working to purge from its list the tens of thousands who have not voted since 2008. Yet missing the last two presidential elections is not unheard of, and the issues of racism and terrorism are sufficiently heated today that setting aside both of the presumptive candidates’ high unfavorables, one might feel that the current stakes are high enough to justify new political participation. Ohio’s turnout in 2012 was lower than that in 2008, and in both elections, there was a sufficient presumption of a large margin of victory that one might have sat out the election. Moreover, long lines at polling places, particularly in urban regions, may have dissuaded people from voting (particularly for those working on an hourly basis and thus unable to take off more time), thus giving a false impression of disengagement. This is all speculative, of course, but there are enough open questions to require that we give serious consideration before making such a strong assumption about those individuals’ interest in voting.
 
Some have made claims as to the normative desirability of higher if not universal political participation, while others are more skeptical as to the merits of enforcing higher turnout among those who are uninterested and/or uninformed. Regardless of where one stands with regard to how politically active one should be in their government, the Constitution’s provision of the right to vote does not come with fine print caveats of “use it or lose it.” While some might look down on someone not being engaged in previous elections, one should celebrate one coming to the party today rather than punishing someone by precluding them from exercising their constitutional right.
 
If states are going to remove voters for inactivity, they should allow same-day registration so as to ensure that those voters, conditional upon eligibility (age, address, identification), may indeed cast their ballot in the given election. But imposing complex rules opens the door increasing election irregularities that may not be at all nefarious, but rather reflections of complex election laws, limited voter information, and limited poll-worker training to manage questions and concerns about such issues as the proper use of provisional ballots, language assistance, disability assistance, the ability to request versus require photo identification, what have you. The headache of providing safeguards against wrongful purging is likely worse than that caused by a voter roll that includes both active and infrequent voters.   

When we go to the doctor, we look for answers, and more than that, we are looking for solutions. We feel better when taking action, even if the evidence-based medicine does not support a given treatment. Perhaps doctors are afraid of litigation in the absence of treatment, with good faith effort at treatment, successful or not, potentially reducing the likelihood that one would take legal action. Perhaps we simply are optimists and think (hope) that we will fall within the range of those (potentially few) who do benefit from a given treatment, and are willing to take our chances. Some have speculated that this desire for action is in part responsible for the high healthcare costs that the United States has (despite the high number of people still not obtaining needed care or having a high share of their income devoted to medical expenses such that they constitute being underinsured.
 
When we look at the candidate for whom to vote, we look at what they have done in office (or elsewhere): how they have voted, what legislation they have introduced, their record prior to taking office, what have you. Our members of Congress champion their efforts at defending issues on their and their party’s agendas – environmental protection, worker rights, healthcare, reproductive rights, economic stability – though admittedly party identification typically predicts voter choice better than does information about particular policy positions and actions taken on those issues. Having a record on which to stand is considered, if nothing else, better than the alternative, and particularly in an election year (such as this) or in the aftermath of a crisis (e.g., a mass shooting), people look to our members of Congress to do something.
 
Members of Congress do not engage in implementation. They draft legislation that delegates to administrative agencies (e.g., Health and Human Services, Environmental Protection Agency, etc.) that carry out the complex tasks of implementation by way of rulemaking and enforcement actions, much of which is highly important but lacks the “sexiness” and the visibility of lawmaking except in particularly controversial cases. Such delegation is justified on the grounds not just of the realities of Congress's workload, but also because bureaucrats have the knowledge and technical expertise from which to draw in promulgating regulations (see, e.g., Chevron v. NRDC). Moreover, unlike members of Congress, bureaucrats are not directly accountable to the electorate, making it more difficult to exert political pressure on those engaged in these important tasks of policymaking. When it becomes clear that action must be taken, we often, then, look to Congress whether or not we are doing so correctly, and members have the electoral incentive to introduce and work to pass legislation that allows them to, if not effect policy change, at least pass the buck.
 
This is dynamic better suited to credit claiming than it is to effecting actual change from the status quo, and an issue that we saw today in the context of the House of Representatives’ passage of HR 2646: The Helping Families in Mental Health Crisis Act, sponsored by Republican Representative Tim Murphy (PA-18). The legislation, sponsored by 207 members, passed with nearly unanimous support with a vote of 422-2.
 
Its passage is immensely important, and personally I was very pleased to see it passed. The legislation does a number of important things. Among other things, the bill creates the position of Assistant Secretary for Mental Health and Substance Use Disorders to take over the responsibilities of the Administrator of the Substance Abuse and Mental Health Services Administration (SAMHSA), extend mental health programs, expand health information technology activities, change the information transmission permissible between mental health care professionals and caregivers, incorporate evidence-based medicine into care provision, and addresses the shortage of the nation’s psychiatric beds.  
 
Undeniably, these are admirable and important goals. The United States has only 11.7 beds per 100,000 people, when 40 to 60 per 100,000 is considered the appropriate standard of care. Up to 1 in 4 primary patients suffer from depression, with 8.9 million having co-occurring mental health and substance abuse disorders. Depression is the second leading cause of disability globally and the leading cause of disability among 18-44 year-olds in the United States, though fewer than half obtain treatment, in addition to which suicide rates are at a 30-year high. And given the high rate at which those with mental illness also have physical illness, and the highly interactive nature of mental and physical health (both given the stressors of physical illness and the fact that neurological, reproductive, endocrine, and other issues can produce mental health symptoms), it is not difficult to see that failures in this domain of medical treatment is immensely important as a matter of public health and safety, as well as economics.
 
But is new legislation the answer? I hesitate to say “no” in that if given the choice between voting yes versus no on mental health legislation, it seems that voting yes is unequivocally the better avenue. Yet we already have legislation that fails to be properly enforced. The Mental Health Parity and Addiction Act of 2008 is federal legislation that prevents health insurance companies from providing less favorable coverage for mental health and substance abuse treatment than they do for physical illness. However, insurance denials on the grounds of “medical necessity”) for mental health are considerably higher (29%) than for physical health (14%), and it was determined that 25% of plans appeared to be inconsistent with the legislation.
 
Further, while the legislation was enacted years ago, it wasn’t until January 2014 that the HHS implemented rules on parity for private insurers, and it wasn’t until March 2016 that it issued rules for federal- and state-funded Medicaid plans covering 72 million low-income Americans, though the new rules will not go into effect for several more months. In a sense, then, we have not yet had any opportunity to evaluate the effectiveness of the rules that were fairly recently promulgated under the legislation that has already been enacted but is not yet being fully enforced.
 
Concentrating on the enforcement of existing legislation is not as good a move from an election standpoint. It doesn’t make as good a stump speech to discuss putting pressure on bureaucrats to incorporate certain comments into their rules and to promulgate them in a timely manner. But passing new legislation is costly in terms of time and effort, and leads to new discussions of new rules that will then take time to go into effect, and there are good arguments to be made that investing even some of the grants from the new legislation toward enforcing the existing legislation would itself mean a great improvement in the lives of those seeking access to affordable care.
 
The legislation sponsored by Representative Murphy is hugely important and I’m glad that the House of Representatives had such an immense show of bipartisan support, and I do hope that the Senate follows suit in the companion legislation that is co-sponsored by Senators Chris Murphy (D-CT) and Bill Cassidy (R-LA), the bipartisanship of which reinforces the reality that this is not a Democrat or Republican issue, but rather a public health issue, an economic issue, a human issue. But ensuring the enforcement of existing legislation will give us a better sense of what new legislation should take on that we haven’t previously, and what we can do better with the legislation that we already have in place and the tools we already have.

I wrote recently on the increased use of emergency rooms in recent years, in parallel to expanded health insurance that people are beginning to utilize for services that previously may not have been obtained. The increased use of emergency rooms and the decline in the number of hospital beds over the same time frame has led to increased wait times in ERs and waiting for admissions amid overcrowding.

Not surprisingly, reliance on emergency room care is not symmetric among demographic groups, and understanding the groups of individuals most likely to rely on emergency care can help in determining the most effective policy interventions to deliver affordable medical services potentially outside the constraints of typical business hours when one may be expected to be at work. The FAIR Health Survey revealed that the age group most likely to rely on emergency care is 18-34 year-olds (followed by those who are 65+), and education level most likely to rely on this is "high school graduate or less," the income level most likely to rely on this is "less than $35,000," and the racial group most likely to rely on this is Latinos (followed by blacks) (source: FAIR Health Survey).  

These demographics should not surprise, given that those who can take off two hours from work to go to the doctor are more likely to have some measure of flexibility in their job, and those who would take off that time to go to the doctor for an outpatient visit may be more forward-thinking, or otherwise more health-conscious with respect to managing one's medical conditions. In contrast, those relying on emergency care, despite emergency care costing far more money, tend to be in poorer health (e.g., because they have waited until a crisis level as opposed to managing on an outpatient basis their conditions) and may have been unable to take time off of work to go to the doctor during business hours (which can be correlated with a lower income and associated health problems).

​Knowing the age and racial groups most likely (relative to the overall population) to rely on emergency care can help us to target solutions toward delivering needed care without further contributing to the burdens of hospitals' emergency rooms. Part of this may entail determining the optimal location for urgent care facilities that operate during longer hours than many doctors' offices but which involve far fewer costs than do ERs (the typical cost of an urgent care visit is $127, compared with over $1,400 for an ER visit), thus concentrating care in the communities where it will be most utilized (e.g., communities with many young families or seniors, Latino communities, black communities). Another part of this may, however, be informational if people are a) unaware of where the local urgent care clinics are, or b) are unaware of the cost differential with respect to obtaining care in different centers under their insurance plans.

A different FAIR Health Survey revealed that people of different demographics factor in different costs with respect to their selection of health plans.  I wrote recently on the rising out-of-pocket costs that patients have been facing in obtaining care in recent years, a trend that has contributed to discourse surrounding underinsurance under the ACA. Among the issues I addressed was the troubling fact that many do not appear to have a clear understanding of the costs associated with their medical plans.

Here, survey respondents were asked the following question: "Which one of the following is your most important consideration when enrolling in a health insurance plan? " Overall, 23% of respondents said that the monthly premium cost was the most important; 23% said out-of-pocket costs; 26% said the primary care physician accepting the plan; 10% said the deductible; and 6% said the number of doctors in the network. However, there is variation across age groups. Those in the 18-34 and 35-44 age groups valued premium cost the most (28%), suggesting that they are more focused on the present (definite) costs as opposed to the longer-term (potential) costs, despite the fact that those plans with higher premiums often are accompanied by lower copayments and lower coinsurance. And while 12% of 18-34 year-olds said that the deductible was the most important (slightly higher than the sample-wide rate of 10%), in general there is an inverse relationship between premiums and deductibles.  

​The notion that those of different stages of life will discount utility differently is hardly surprising, but the fact that younger people both value lower premiums and are most likely to rely on emergency care is an important and troubling from an economic standpoint as we examine rising out-of-pocket costs and underinsurance. This should factor in to how we expect younger people to purchase insurance, and how we might be able to counsel people to better obtain plans that fit their actual usage and to obtain care that better minimizes costs than does reliance on the notoriously expensive emergency care. 

It has been observed that emergency room visits have increased in recent years in the aftermath of the implementation of the Affordable Care Act as individuals are able to obtain coverage for care that they otherwise would not have sought. Between 1995 and 2010, annual ER visits grew by 34% while the number of hospitals that had emergency rooms actually declined 11%. Such trends are particularly prevalent among those states that opted for Medicaid expansion under the ACA, with Louisiana being the most recent state to adopt this policy.

Indeed, a 2015 survey of physicians revealed that three quarters observed that emergency room visits had increased, whether greatly (28%) or slightly (47%). This is in contradiction with the expectation that with more expansive health coverage, individuals would have access to physicians non an outpatient basis and manage medical conditions without the need for emergency care. (There is, of course, the reality that people are not always able to obtain medical care during business hours when they must be at work, while emergency rooms operate 24/7).  
 
Approximately 12% of emergency room visits result in hospital admissions. With rising levels of emergency care, there is a question of whether hospitals are adequately prepared for larger numbers of patients potentially requiring not just emergency treatment, but hospitalization. It was reported by the Treatment Advocacy Center that the number of psychiatric beds has declined markedly over the years, with the United States having only 3.5% of the number of psychiatric beds that it had in 1955, nearly 20% fewer than the United States had in 2010.  To what extent was that true of hospital beds more generally?
 
Consistent with some observations regarding hospital closures in order to emphasize outpatient care, I evaluated the Kaiser Family Foundation data from 1999 to 2014 on the number of hospital beds per 1,000 people per state, as well as the number of emergency room visits per 1,000 people per state, and find declines in the number of hospital beds alongside increases in the amount of emergency room care. This increase in ER visits does not appear to be a substitution of outpatient care for emergency care, as the number of outpatient visits also has increased over time. Rather, with a greater number of people having at least some degree of health coverage, they are newly seeking care for things otherwise being left untreated. 

I then evaluated the Kaiser Family Foundation data within states, normalizing the numbers of hospital beds and emergency room visits to fall within the range of 0 to 1 so as to facilitate easy comparison on the same scale. In almost every state (South Carolina being the lone exception), we see the trend of hospital beds versus emergency room visits parallel to the trend nationally, with increasing ER visits and stable or declining hospital beds. 

This can result in increased emergency room overcrowding, which can adversely impact patient care. For example, between 2003 and 2009, the average wait time in emergency rooms increased 25%, with longer wait times in urban regions. As a consequence of overcrowding, 50% of ERs are operating at or above capacity, with 90% of emergency rooms reporting patient boarding while waiting for hospital beds to open up for those patients being admitted. Moreover, 500,000 ambulances are diverted annually from the closest hospital as a consequence of such overcrowding.
 
There clearly is much need for improvement. The Healthcare Triage medical videos highlighted the advantages of retail clinics, which can help to offset the burden that emergency rooms face in addressing acute medical problems during off-hours, particularly those not requiring extensive medical training (e.g., ear infections, urinary tract infections, sports injuries, strep throat). Urgent care centers, while not unlimited in their scope and certainly not addressing severe issues (e.g., heart problems, severe bleeding, etc.), can address a wider range of health conditions not on a 24/7 basis, typically have longer hours than do primary care practices and operate on a walk-in basis for those unable to get appointments with a primary care physician. While emergency rooms will not turn away patients, they will not necessarily alert patients to the existence of local urgent care clinics that may be both more affordable and more convenient, relieving both the ER and the patient of the burden of longer wait times. (Of course, if there is a likelihood of admission, the ER would be the proper venue in which to seek care).
 
Enhancing psychiatric treatment options is also going to be an imperative aspect of the policy solution, though it is far from simple. After all, 1 in 8 emergency room visits are related to mental health and substance abuse (with 2 in 5 such individuals rating their emergency room experience as “bad” or “very bad”), though there are only 11.7 psychiatric beds per 100,000 people in the United States (whereas a minimum of 40 to 60 is recommended). This increasing boarding in emergency rooms while waiting for hospital beds can put greater burden on ER resources, leaving doctors and nurses stretched thin with respect to both psychiatric and medical care. And somewhat relatedly, improving services to low-income populations is essential to relieving both emergency room and hospital admission burdens. Anyone who has spent extensive time in emergency rooms is familiar with each hospital having a number of “frequent flyers,” whether due to homelessness, mental illness, or drug or alcohol abuse (or some combination among the three) in search of shelter and food. Further, absent clean and safe living conditions, one is more likely to be exposed to pollutants or extreme temperatures that can contribute to respiratory problems, to have malnutrition, to be subjected to crime and related traumas requiring intensive treatment, and to find it more difficult to keep a wound clean and free from infection. Improving interventions in low-income communities and among those in need of affordable mental health care will be essential to delivering essential care while not further contributing to the burdens that American hospitals increasingly are facing. 

​Full post here. 

​There has been rampant news of the numerous deaths and hospitalizations tied to opioid abuse, with marked rises in such abuse and deaths in the last two decades. As a consequence, 49 states – all but Missouri, where I reside currently – created some form of prescription drug monitoring program (PDMP) to identify high-risk prescribing and patient behavior (for example, hopping among doctors from whom patients are obtaining or seeking to obtain opioid prescriptions). Scholars at Vanderbilt found that a state’s implementation of a PDMP was associated with a reduction of 1.12 opioid-related overdose deaths per 100,000 people in the population in the year following the program’s implementation, with greater effects in those programs that were more vigorous (e.g., monitoring greater numbers of drugs).
 
Missouri is a curious case in this regard because while it ranks high in the number of opioid prescriptions per person (it falls within the category of 82.2-95 prescriptions), it is the lone state that failed to adopt a prescription drug monitoring program that would help to avert deaths and other medical complications as a consequence of this high rate of prescribing. But unlike many states in the US, while not monitoring opioid prescriptions within the State of Missouri, they prohibit patients from filling prescriptions of any sort by physicians from other states.
 
Let’s think about the practical implications. When I moved here from New York, if I had wanted to, I could have gone to ten different Missouri doctors for Vicodin or Percocet and they would not have been able to monitor that behavior that would have been unequivocally suspect and unhealthy. However, I was unable to fill the prescriptions from my New York doctors for Zofran, which is an anti-nausea medication, and for calcitriol, which is a specific form of vitamin D. Neither medication has any remote habit-forming property. The pharmacist’s explanation for my inability to fill prescriptions for these medications that from an addiction standpoint are completely innocuous (though are very valuable to me!) was that Missouri was working to combat drug abuse and addiction.
 
If that is true, and by all accounts it should be true (in addition to high rates of opioid prescribing, meth lab seizures increased 37% between 2007 and 2009 and is around the national average with respect to drug-induced deaths), the State of Missouri should think more carefully about the policies best targeted at the problem. After all, the culprit with respect to opioid prescribing and abuse is not likely to be licensed physicians in neighboring states issuing excessive prescriptions for addictive medications (and if that is a particular problem, regulating out-of-state prescriptions for controlled substances would be a better policy to adopt than the more general constraint currently imposed), but rather individuals shopping for prescriptions among doctors within their region. When we opt for a federal or state government intervention, it should be tailored to the ill that it seeks to cure. (An unrelated though timely example is some individuals' misguided discussion of bans of automatic weapons in the aftermath of the Orlando shooting, because while tighter gun control overall would be preferable to many, it would not have impacted the shooting, which was done with a semi-automatic weapon). To preclude one from filling an anti-nausea prescription from a New York doctor while theoretically allowing the filling of ten opioid prescriptions from Missouri doctors does nothing to curb the opioid abuse problems that persist in the state.