Throughout the presidential campaign, and in particular in the last month, ample attention has been paid to the candidates' physical and mental health, and in turn their suitability as President Obama's prospective successor. Most recently, Mika Brzezinski of MSNBC's Morning Joe said that a mental health professional should come on the show evaluate Donald Trump and his suitability to be president. To his credit, co-host Joe Scarborough pushed back on that proposition because he could not be diagnosed on the show (see the Goldwater Rule, according to which the American Psychiatric Society prohibits psychiatrists from offering professional opinions about candidates whom they are not themselves treating), though Mika still suggested that a psychiatrist could discuss the character traits that Trump has routinely exhibited and that provoked in her concern.

This was far from an isolated discussion. Obama campaign advisor David Plouffe held that Trump's behavior met the "clinical definition" of a "psychopath." Others -- some mental health professionals and others mere observers -- have likewise weighed in with such "diagnoses" as narcissistic personality disorder and antisocial personality disorder. And while Trump's medical evaluation was supposedly drafted by his own physician, a number of commentators and journalists (and physicians) have called attention to the problems -- from the lack of specificity, to the grandiosity of language that in many ways parallels that of the candidate himself, to the difficulty in even identifying the physician's practice. And while what was at stake was not so much Trump's actual health, what remains clear from this exchange has been the extent to which the American people apparently feel at liberty to make these evaluations that even professionals are not permitted to provide from afar. 

This has not been an isolated incident. Indeed, Martin Shkreli tweeted that he believed Secretary Hillary Clinton to have early onset Parkinson's Disease, thus sparking an extended discussion as to Clinton's health and thus fitness as president. Not only is Shkreli not her physician, but he is not a physician at all. Given the physical and intellectual demands of the role of President of the United States, it is altogether appropriate to seek assurance of fitness for office. That is why it is a norm to make public a physician letter attesting to the state of candidates' (or officeholders' health). 

The public discussions of Trump's mental health may be amusing for the casual observer of this admittedly unusual presidential election season, and for those often finding themselves aghast at the controversial statements that he continues to make on Twitter and elsewhere. But to conflate discussion of mental health with discussion of the genuinely distressing prejudice at the heart of much of his messaging on race, immigration, religion, and the like, does us all a disservice. If Trump's policies rub one the wrong way, it is not likely because of a DSM-V Axis II personality disorder diagnosis but rather because of a fundamentally different view of foreign policy as well as the importance of respecting diversity in a pluralistic society. By waving away racism, sexism, and ignorance and instead characterizing it as a mental health problem, rather than offering answers amid this election season, it perpetuates already pervasive problems of stigma surrounding mental illness, a stigma that inhibits many from seeking treatment that might aid them in recovery. We can and should do better than that. 

Writing off Trump's disposition as a mental health problem also ignores a far greater issue, which is that Trump's success would not have been enabled were it not for millions of voters with whom his message, for better or worse, has resonated. Mentally ill or not, Clinton victory or Trump victory on November 8, there will be over 14 million people who supported him in the Republican Party primary and who those continuing on in politics will need to court in order to secure continued electoral gains. Candidates, commentators, and activists would do well to focus on the Trump voters while leaving the candidates' health to those in a position to offer sound professional opinions that will not undermine efforts at broadening willingness to access needed healthcare.

“Let’s go for a road trip,” Bruce says with a smile, guitar in hand, between “Working on the Highway” and “Darlington County” (alas, absent the Nils-sized hat accompaniment). And indeed, that comment is quite apt for a concert by Bruce Springsteen , whose fans are known to take planes, trains, and automobiles to attend his shows, even crossing oceans to experience Boss Time in all its glory.
 
For those who do not know the love for his music, it is strange to invest so much time, money, and energy into a concert. For those who are his devoted followers, happily spending a day in a New Jersey Meadowlands parking lot during sound checks to hopefully fare well in the general admission pit lottery, it is more than a concert. It is a religion. It is faith. It is spirit. It is “getting gotten” by 60,000 strangers who for that for hours are sharing a spiritual experience in which redemption and hope are fair game as sparks fly on E Street.
 
There are times in life when feels elusive, when we are left wondering when or if we will, to paraphrase Hemingway, come to find strength in the broken places of our lives. There are times when even providing our pound of flesh still leaves us thinking, to quote a certain Boss, “Is a dream a lie if it don’t come true, or is it something worse?” Enter Bruce Springsteen, long-time champion of America’s working class heroes, instilling in tens of thousands of followers each concert some much needed assurance that faith can and will be rewarded, and renewing belief in the promised land.
 
Bruce’s sound checked songs do not reliably make their way onto final setlists, but this first of three MetLife shows in East Rutherford, which began at 8:05pm and went until midnight, was an exception as the string section walked onstage in advance of the full E-Street Band, which then not just played, but opened with “New York City Serenade,” a fantastic concert rarity from his second album, The Wild, the Innocent, and the E-Street Shuffle (1973). From that moment onward, it promised to be a special show and it delivered, the entire audience serenaded and on its feet for four hours.
 
Seeing Bruce in New Jersey always comes with a couple of downsides (at times aggressive fans and a poorly-located venue), but the perks outweigh them tenfold, from the extra cheers for local spots (“My home is here in the Meadowlands… the blood is spilled, the arena’s filled, and Giants play the games”) and an energy in the band that is consistent with a happy homecoming. And on a perfect summer night (a vast improvement over his September 22/23 concert in 2012 in which a two-hour rain delay led to it being his effective “birthday concert”), Bruce came ready to celebrate summer with such songs as “Spirit in the Night” and “Something in the Night,” and joking with a fan’s sign request of “Santa Clause is Coming to Town” that it was “a good summer song.”
 
Perhaps because of Bruce’s upcoming autobiography release, he has return this tour to more storytelling. Before launching into a heart-wrenching performance of “Independence Day,” he shared stories of his father’s virtual non-responsiveness to his music, a central theme of which is his strained relationship with his father and his struggle to connect with him. Indeed, Bruce shared, absent the ability to have a real conversation with him, he sent his father his records, which his mother forced him to listen to but which provoked from him no commentary until shortly before his death. As with so much of his work, the show was deeply personal.
 
Something noted widely in the aftermath of First Lady Michelle Obama’s speech at the 2016 Democratic National Convention was the power of her commentary on Donald Trump without ever invoking his name. The audience got a similar experience with Springsteen, whose progressive politics are well-known (many love him for that, and others such as New Jersey Governor Chris Christie love his music despite his politics). The audience got a three-song sequence of “Mansion on the Hill,” “Jack of all Trades,” and “My Hometown” – all powerful songs that carry with them messages tied to economic inequality and a call to support the working class. Then after a stunning performance of “The River,” Bruce launched into “American Skin (41 Shots),” which was written in the aftermath of the fatal shooting of the unarmed young man Amadou Diallo in the Bronx and which remains immensely relevant amid extensive dialogue of racial profiling in policing as well as gun violence more broadly. The intensity of this election season is not lost o him (and a larger-than-usual number of signs read “Bruce for President”), but on stage he let the music speak for itself, and the message rang loud and clear.
 
To be sure, Bruce played a number of the usual crowd favorites (for example, “Badlands,” “Out in the Streets,” “Because the Night,” “She’s the One,” and “Rosalita”). Among the songs from The River that were played (he no longer performs the album start to finish) were “The Ties that Bind,” a rocking “Sherry Darling,” and “You Can Look (But You Better Not Touch),” which is admittedly an ironic song for a musician notoriously flirtatious and known to crowd surf still. But Bruce also broke out some less common ones thanks in part to his taking song request from the audience. One person had a “Growin’ Up” sign because it was his thirteenth birthday, leading Bruce to play the song but not before joking that he wouldn’t get into what he was up to at that age. “Brilliant Disguise” was another rarity that was a real highlight from the generally underrated Tunnel of Love.
 
Jake Clemons had big shoes to fill, both literally and metaphorically, and he has done a stupendous job on the saxophone and in joining Bruce to ham it up on stage as only Bruce can do. Jake’s sax finesse is showcased no better than in “Jungleland,” which for some period had made the loss of Clarence feel all-too-acute and which now is a stunning example of how the E-Street Band can itself find redemption in a member of the Clemons clan who is truly one of them now.
 
There are a number of classic rock artists who to be sure have withstood the test of time. Peter Gabriel, Tom Petty, The Rolling Stones, The Who, and Billy Joel, among others, are notably excellent performers. But watching this nearly 67 year-old rocker on stage, in better physical shape than most of his fans young and old, putting on four hours of singing, dancing and fist-pumping without intermission, one cannot help but be reminded that there is no other artist who gives so much too – and indeed demands so much in return from – his audience, some of whom arrived for the general admission lottery at 10am. Bruce is known for long concerts and for never really wanting to leave, such that one can often leave a venue with the trepidation of “That was the end, right? He didn’t go back on, right?” Because until the house lights come on, it’s fair game for an encore. Despite going through his traditional closing songs – “Dancing in the Dark,” “Rosalita,” “Tenth Avenue Freeze-Out,” and “Shout” – he splashed water on his face, Steve threw around his shoulders a mini-cape reading “The Boss” on the back,” and Bruce did a faux-shy dance up and down the stairs “deciding” whether to stay on stage for more. Next came a spectacular “Bobby Jean” and in response to another birthday request and oh-so-fitting for a summer night in New Jersey, “Jersey Girl” to close out the night at the midnight hour.
 
No doubt, a large share of that crowd looks forward to being serenaded again by the “heart-stopping earth-shocking earth-quaking heartbreaking, air conditioner-shaking, love making, Viagra taking, history-making, legendary E-Street Band” tomorrow night. 

I wrote a few weeks ago on avenues to expand the number of individuals able to obtain affordable healthcare (see here for abridged piece on KevinMD). This piece responded to the reality that poor reimbursement rates for psychotherapy by psychiatrists have led to markedly lower rates of accepting insurance relative to other medical specialists (with only 55% of psychiatrists accepting insurance, compared with 93% of other medical providers accepting insurance and 86% accepting Medicare), along with less lucrative reimbursement to primary care and geriatric physicians despite the wealth of evidence supporting their being essential to managing chronic conditions well. That individuals who are poorer will be unable to obtain psychiatric care is particularly problematic given that 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 not in poverty. Improving care in these three domains will be essential to managing chronic conditions well, and to better managing mental health both in itself and also in interaction with physical health. This will also help to curb the rising costs that we face given relatively poor access to primary and psychiatric care that many patients have, thus leading to more expensive care down the line. 

We cannot reasonably expect physicians to fill the gaps in care if insurance companies do not make the environment conducive to doing so in a time of high medical school debt (on average,  $180,723) while physician salaries overall are actually declining. They must incentivize insurance participation in ways that will not produce losses for the doctors seeking to provide care while getting out of debt and reaping the rewards of their hard work. Yet with 46.8% of respondents citing the reason for unmet mental health care being cost or insurance issues, the dearth of adequate care for those of lower and middle classes must be addressed.
 
One potential avenue to balancing insurer and physician priorities in healthcare provision is to provide government tax credits to insurance companies willing to provide higher reimbursement rates for the less lucrative, but clearly evidence-based psychotherapy, primary care, and geriatric care. While primary care physicians are not trained as psychiatrists (beyond a psychiatry rotation in medical school), they currently provide approximately half of the mental health treatment in the country, with approximately 25% of primary care patients having a diagnosable mental health condition. Yet the national-level starting salaries in general internal medicine, geriatrics, and psychiatry are $180,000, $184,000, and $185,300 respectively, compared with, for example, $232,500 in OB/GYN, $325,000 in hematology/oncology, and $337,500 in gastroenterology. The rates of reimbursement do not incentivize entering these fields in the first place, leading to marked shortages of psychiatrists such that 59% of specialists are at least 55 years old. Moreover, once within a given specialty, the insurance system’s current schedule of reimbursements does not incentivize engaging in the well-supported but less lucrative aspects of the field (e.g., a 45-minute psychotherapy session with a psychiatrist as opposed to three 15-minute medication management appointments).
 
The shifts in insurance reimbursement rates should take a few forms. Given the pressures that primary care physicians face in providing mental health care, insurance companies should allow physicians to bill for longer or more involved appointments when mental health interventions are required extending beyond a simple check-in on symptoms, vitals, and medication management. Absent the ability to do so, physicians are effectively taking losses when providing that added (and needed) care for these higher need patients.
 
The ability to bill insurance for higher rates for primary care appointments will do much to address the shortage of primary care physicians that the United States faces, and within that to address the shortcomings in the earnings that existing PCPs face when addressing their patients’ mental health (and other complex) needs. This ability to bill more for longer appointments will be particularly essential in the domain of geriatrics, given that not only do we have a shrinking number of geriatricians despite an aging population, but the needs of such patients are often diverse and spanning both physical and mental health.
 
Second, having higher “customary and reasonable” rates for psychotherapy will allow for psychiatrists (and non-MD psychotherapists) to practice the well-supported psychotherapy and integrated therapy and medication, without experiencing the same financial deficits that they do currently. Insurers typically designate the “usual and customary” fee for a 45-minute psychotherapy session to be $225 in New York City even if a practitioner’s private practice rate is $300 or more (which in that region is quite common), compared with a "usual and customary fee of $125 for a brief medication appointment (meaning 3-4 of such appointments per hour). It is not difficult to see why one would be less than inclined to accept insurance for psychotherapy, especially given the added burdens of claim submissions and the like. While not being as lucrative as multiple medication management appointments per hour, raising the “usual and customary” fees to better approximate the average charges for psychotherapy in the region will help to close the gap and do more to encourage such a practice of more integrated mental health treatment. Indeed, by raising by $50 the fee recognized by insurance, psychiatrists could raise in-network earnings expectations by tens of thousands in annual income if operating a full-time practice.

Changing insurance reimbursement schedules to such a degree is far from a costless enterprise, which poses particular challenges given that private insurance companies are by definition for-profit and yet have already in many cases reported losses in recent years in the aftermath of the Affordable Care Act. In addition to ensuring these changes within the government-sponsored health plans, providing government-sponsored tax incentives for private insurers to adopt these changes for all plan participants would nevertheless be an important first step in triggering these improvements to the American healthcare system, allowing physicians the greater financial freedom to enter areas of medicine in which we have a dearth of practitioners, and once practicing, to provide the best evidence-supported medicine.
 
So often, we express woes as to the extent to which we spend money on the American healthcare system and yet obtain poor results. Indeed, one in every six dollars contributed to the US GDP spent on healthcare but compared with other nations, the US has a lower share of residents covered, fewer hospital and physician visits, and high rates of obesity, infant mortality, and chronic disease such as diabetes and heart disease. This can be disheartening to policymakers and advocates who understandably seek to see positive outcomes emerge from such heavy investments. It is only natural to want money to be well spent, not to mention to want a population physically and emotionally healthy enough to be productive in a diverse economy. While reducing healthcare spending is unlikely to be the solution given the immense gaps in care, reallocating healthcare spending might be.
 
Better facilitating integrated physical and mental health will be essential to the progress that the United States hopes to make in this domain. By ensuring mental wellbeing, individuals may be more invested in staying on top of their physical wellbeing, and may be less prone to such issues as substance abuse. When well cared-for physically, the stressors and anxieties of health may be alleviated. And while we paint in broad strokes the need to do better in this regard, we have done little to improve the means to ensure better care for those who cannot afford massive out-of-pocket expenses. Incentivizing insurers to make it more financially sound to enter the areas of medicine at the forefront of the physical and mental health integration – primary care, geriatrics, and psychiatry – and to incentivize modes of care better supported by evidence-based medicine (whether the ability to bill more for longer primary care and geriatric appointments when addressing additional mental health concerns, or the use of psychotherapy in addition to medication) – will be essential starting points en route to ultimately mandating insurers’ provision of such higher levels of coverage. It will additionally offer health researchers evidence on the effectiveness of such incentive structures in encouraging broader in-network participation, and the responsiveness of patient populations as we work to improve US health outcomes.
  
Public health and economics can certainly be at odds with one another, but they needn’t be when looking at the potential cost savings of avoiding hospitalization (whether physical or psychiatric) or problems associated with prescription drug non-adherence or being on disability or unemployment insurance due to the exacerbation of physical and/or mental illness. Smart investments today can yield payoffs down the line.

​En route from Manhattan back to New Haven late at night last week, the fellow passenger asked me what I do. I said that I’m in academia, and when pressed “confessed” that I’m in political science, then bracing for the cringe-worthy demands of exclamations of how Donald Trump’s nomination could have come to be. (I haven’t an answer).
 
But what this man said also was that he felt frustrated at how “rigged” he viewed the system. “Don’t you think the system is rigged?” he pressed me, and then was surprised by my emphatic response of “No.”
 
The use of the word “rigged” is one that has figured prominently in the campaigns of Bernie Sanders and Donald Trump, who while embracing very different world views from a policy standpoint both embraced the anti-establishment sentiment for which a large share of the American electorate seemed in search.
 
The notion that a system could be rigged takes away the notion that one might, indeed, lose in a fair system (“fair and square,” as they say). There are indeed examples of rigged systems. We see such evidence in elections won with 95% of the vote such that any opposition candidate is inconsequential if ever legitimate. We see evidence when voting machines switch votes for presidential candidates and the executive leadership of voting machine companies writing a letter pledging commitment “to helping Ohio deliver its electoral votes to the President” in 2004, the outcome of which was determined by the State of Ohio. We do not see evidence of rigging in 2016, but rather the petulance of one unwilling to concede at the conclusion of a loss. This is not a view that is contingent upon a Clinton versus Sanders nomination, a Trump versus Rubio nomination, but rather based on the empirics of the admittedly eye-opening election season that we have witnessed unfold over the last several months, presenting more than our fair share of surprises but not corruption in the way that "rigging" suggests. 
 
It is not because our electoral institutions are perfect. They are not. But if it were a truly rigged system, it is unlikely that two such non-conformist candidates would have fared nearly so well. Despite Sanders’ loss to Clinton in the Democratic primary, he vastly outperformed predictions and, while losing by a more marked margin than did Clinton to Obama in 2008, still came remarkably close considering where he started out. It is far from controversial to say that Trump’s garnering of the Republican Party nomination defied expectations.
 
Characterizing the US electoral institutions as rigged not only mischaracterizes reality – with the empirical fact that “outsider” candidates fared well on the Democratic side and won on the Republican side – but it takes away from those who have won honestly, fairly and squarely. It is all well and good to want to change the system when in office, and by all accounts we do need to change certain electoral institutions. We have a decentralized election system that is confusingly varied by state, that in many cases disenfranchises ex-offenders, that in many cases requires the provision of identification that has a disproportionately adverse impact on minorities. We also have recently demonstrated some vulnerability to hacking, which incidentally could indicate some rigging (though largely in favor of those alleging rigging in the first place).
 
But the first step isn’t to complain about the process. It’s to win playing by the rules of the game, respecting the process (even respectfully disagreeing), and to create fairer rules from within office. 

Within Congress's passage of the Employment Retirement and Income Security Act (ERISA) was the Consolidated Omnibus Budget Reconciliation Act (COBRA), through which group health plans by employers are obligated to provide employees temporary health insurance at no more than 2% above the full costs, when that employee's job was terminated (resulting in what would otherwise be the termination of their medical benefits). 

As a social scientist lately occupied with health policy, I was well aware of this program but had not experienced it firsthand until recently. The disastrous experience seems to warrant discussion both as an academic and as a frequent patient. 

For starters, their checks are deposited separately from the processing of patient information, meaning that they can deposit a $700 check without confirming that they have the needed information to send to the insurance company to guarantee coverage. In fact, they can forget or otherwise err in processing information (as they did with me) despite having deposited such a large sum of funds (for perspective, it is approximately the median rent of a one-bedroom apartment in the United States), and absent the patient information in their database, they have very little if any way to look one up in the event of a complaint about lack of insurance coverage, and no way for the insurance company itself to know that one is entitled to coverage. 

If one does need medical care in a hospital setting (as I did), with the still-pending status of COBRA, one gets the additional stressors of daily visits from hospital case managers informing them of lack of coverage, and several calls afterward from the hospital in its effort to recoup payment. Hospitals are hardly at fault for this, and have a vested interest in both patient care and reimbursement with which the slowness of this process interferes. 

Absent insurance coverage being renewed (they will tell you that it is backdated to the first day of the month for which payment was provided, and that is true, but there are important caveats), one cannot obtain coverage for prescription medications, as insurance benefits must be verified by the pharmacy before they are applied to one's payment for medication. While some medications may be cheap out of pocket, others most definitely are not, and regardless the patient population for which COBRA is designed is those who are unemployed/between jobs, and thus presumably do not have the disposable income to spend on excess medication costs. And needless to say, any out-of-network claims are not processed by the insurance provider because one is no longer appearing, from their perspective, to be covered.

The number of calls to COBRA that can be required to sort out the details of one's case are astounding. They do not reach out to one with any speed, so it is largely the burden of the patient to follow up and ensure that information is being processed. In one instance, they neglected to process the form altogether. In another instance, they neglected to mention that the patient date of birth was missing, and that missing information precluded sending any information to the insurance provider (an information omission of which I was never informed until calling at my own initiation to follow-up). The birthdate and any other information changes cannot be made over the phone as with any other carrier with whom one might need only answer a few questions for security reasons. Rather, one must go online for forms, they must be filled out, printed, and mailed or faxed. All told, it required two case reference numbers, four customer service representatives, five weeks, and two mailed letters to guarantee insurance coverage for the month of July, meaning that it will be confirmed after the benefits lapsed, meaning that the prescription drug benefits were effectively nonexistent (at a time when many people struggle to afford needed medications, a non-adherence problem that produces a number of medical problems of its own for many Americans). 

Programs such as this are meant to protect those who are vulnerable -- those who are poor, who have lost their jobs, and who need healthcare. These are likely not the people who will navigate well a labyrinthian system with several letters, case managers, micromanaging the information transmission among patient, employer, COBRA, insurance providers, and physicians. 

There are many problems in the United States that are incredibly difficult to solve. Much of our added healthcare costs from which we do not reap the benefits can be attributed to costly procedures (much more costly than in many other countries) and costly medications. Too many people are underinsured, facing high deductibles and other out-of-pocket costs. We have marked income inequality and wage gaps education gaps and health inequality. These are problems that have taken years to address and will take many years still. Addressing this bureaucratic red tape should not.