After an election dominated by rhetoric and anti-establishment sentiment more so than policy specifics, the upset of November 8th left open many policy questions as to the course on which President-Elect Trump would steer the nation. More questions still were raised when it was suggested that some aspects of the Affordable Care Act might, indeed, be salvaged. Such hopes have recently been dashed.

Among President-Elect Donald Trump’s recent cabinet announcements is that of Health and Human Services, for which he has chosen staunch ACA and reproductive choice opponent Representative Tom Price. While qualified for the position as a long-time orthopedic surgeon and member of Congress, much of his political record are deeply troubling in looking to the future of the American healthcare system.

To a long-time observer of American politics, it comes as little surprise that there is ample politics in policy. Yet one domain in which this can be troubling is that of healthcare. After all, cancer, heart disease, and diabetes do not discriminate among Democrats and Republicans. Physicians treat patients of different ideologies and socioeconomic status, and following the Hippocratic Oath they look after the safety and wellbeing of those who are in their care.

To be sure, physicians have their own policy and partisan preferences, though typically they are not (or should not be) on display in an exam room. Indeed, there are are matters of healthcare that may well be in contest with one’s own partisan politics, such as the virtues of Medicaid expansion under the ACA or access to women’s health clinics that, among many other services such as cancer screenings and family planning services, do provide abortions. While scaling back the ACA and restricting access to clinics such as Planned Parenthood is a popular talking point for members of the Republican Party, many physicians see the benefit that their patients reap from obtaining insurance regardless of preexisting conditions and from obtaining affordable contraception.

Yet Mr. Price, placing his partisan politics above medical judgments in many prominent respects, does not recognize these benefits. Rather, he has been among the fiercest opponents.

Indeed, in 2015 he co-sponsored HR 3134, the Defund Planned Parenthood Act of 2015. He has additionally voted against Infant Mortality Pilot Programs (2010), Funding to Combat AIDS, Malaria, and Tuberculosis (2008); Children’s Health Insurance Reauthorization Act of 2007, and he has voted in favor of repeals of provisions of the ACA.

As an orthopedic surgeon whose residency was completed at Emory University and after which directed an orthopedic division of a large hospital in Atlanta, Mr. Price likely saw patients of a range of ages, from younger athletes to more elderly patients whose injuries associated with older age required treatment. And having provided these medical services at major hospitals accepting both Medicare and Medicaid, rather than serving wealthy private-pay clients who would seek medical attention without regard to insurance status, Mr. Price doubtless saw the benefits that his patients reaped from having access through these government programs to the care that aided their healing and mobility. These programs accepted by the hospitals at which he provided care, and from which his patients benefited, are the very programs that he seeks to privatize, thus stripping federal protection of these core medical benefits for seniors and the poor.

Mr. Price may have pledged to do no harm as a practicing physician, but as a legislator and presumptive Secretary of Health and Human Services, it is difficult to see as anything but deeply harmful his assault on programs that care for the physical and mental well-being of some of the most vulnerable subsets of the population.

While Mr. Price and his family currently live a life of much privilege, as a father no doubt Mr. Price understands the fear that a parent would have should their child fall ill when medical treatment is difficult to come by. And as a resident and then attending at major hospitals, no doubt Mr. Price treated families experiencing just those concerns, which the Children’s Health Insurance Program (CHIP) works to address by providing health care coverage to over 8 million low-income children. And yet despite knowing — and as a physician, seeing up close — the importance of delivering quality, affordable healthcare to children so that they may go on to thrive in their adulthood, Mr. Price voted against its reauthorization.

Among the most deeply partisan issues of the recent election cycle was the expansion versus repeal of the ACA which — for all its faults with respect to continued underinsurance of millions — expanded the number of insured Americans by approximately twenty million. As someone who practiced as an orthopedist for over twenty years, Mr. Price should know the impact that insurance coverage has on one’s willingness to pursue treatment for their injuries, and the sometimes dire consequences of going untreated due to lack of insurance. Despite this, he has sought to repeal the Act, challenging the “stifling and oppressive federal government,” with the GOP replacement plans all estimated to reduce the number of insured Americans and the extent to which they are covered. If there were any doubt as to Mr. Trump’s seriousness about dismantling the ACA, those doubts have now been vanquished.

As both a politician engaging in diverse matters of public policy, and as a physician who had many patients with diverse stories, Mr. Price no doubt understands the important role that mental health plays in physical health as well as worker productivity and potential proclivity toward substance use and abuse. Indeed, Mr. Price’s own state of Georgia ranks 47th out of 51 in access to mental health care according to Mental Health America. This carries physical, emotional, and economic consequences, with major depressive disorder costing an estimated $210.5 billion, raising the prevalence of other medical conditions that require treatment (which carries additional expenses and stressors), and in extreme cases, suicide.

The legislation of which Mr. Price has been a fierce critic, the Affordable Care Act, created one of the largest expansions of mental health and substance abuse coverage in a generation. Among its requirements were that all marketplace insurance plans, and most individual and small employer health insurance plans, provide coverage for mental health and substance use treatment services. While some attention has been paid to addressing ways to continue to protect those with pre-existing conditions, Mr. Price and his Republican colleagues have yet to provide answers as to the future of mental health treatment in the absence of the ACA, whose progress has not yet had the chance to be fully realized. Leaving these populations of individuals, already vulnerable, without an affordable means to address mental health or substance use concerns, would be deleterious to their physical health, and well beyond what many physicians would deem permissible.

Moreover, while opposition to abortion access is a position commonly held among those on the right, the Planned Parenthood clinics that Mr. Price has sought to defund provide a range of affordable family planning services that contribute to the physical and economic well-being of the nation. The National Campaign to Prevent Teen and Unplanned Pregnancy estimated that the cost to taxpayers associated with teen childbearing was $9.4 billion in 2010 alone. As Figure 1 illustrates, greater access to Planned Parenthood clinics is associated with marked declines in teen childbearing, with my own research showing additional effects of curbing sexually transmitted diseases and HIV.
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​Similarly, Figure 2 shows that greater access to women’s health clinics is associated with lower rates of sexually transmitted disease diagnoses, the medical treatment of which aggregated to an estimated $16 billion in 2010. These issues will never disappear, but they can be minimized by maximizing access to these medical services that Mr. Price has shown himself committed to eliminate. The Vice President-Elect Mike Pence is himself, though vehemently pro-life, well-acquainted with the pitfalls of aggressively curbing access to Planned Parenthood clinics, with his slashing of funding to the organization in Indiana sparking an HIV outbreak in Scott County, which in the absence of Planned Parenthood no longer had an HIV testing center.

The outcomes of fewer teen births and fewer STD diagnoses are surely beneficial from both medical and economic standpoints, and yet even as a physician this information has yet to sway Mr. Price in his vehemently supporting the organization’s defunding and even going so far as to dispute that any women struggle to afford birth control. He even went so far as to cosponsor in his first year as a congressman HR 552: Right to Life Act, which was legislation to define personhood in the 14th Amendment of the Constitution as beginning at the point of fertilization, without any exceptions listed with regard to rape, incest, or the health of the woman. While an orthopedist and not an obstetrician, as a physician Mr. Price surely had some female patients, and as their physician it was incumbent upon him to provide them with the best care. That care does not include contributing toward their being sentenced to motherhood because they were subjected to a violent crime, nor should it include forcing a woman into a life-changing decision that would carry a high risk of compromising her health and safety.

One cannot expect a cabinet appointee to be devoid of partisan preferences. Indeed, partisan political experience often contributes heavily toward their nominations. And unlike the selection of Senator Sessions for Attorney General, despite his staunch conservatism even relative to his own party (see Figure 3), Mr. Price does not present existential threats to democratic institutions, but rather strident challenges to policy issues that too often are rendered partisan.
​
However, the consequences of Mr. Price consistently ignoring the empirical evidence in favor widely-used healthcare programs — even despite his medical expertise — have both vast economic and human consequences that will be all the graver upon his presumptive confirmation as Secretary.

​

Note: An abridged version of this piece appeared in The Guardian on November 30, 2016.

​On November 8, Americans had an opportunity.
 
We had an opportunity to reject the cynicism and unbridled fear on which Mr. Trump’s campaign was based.
 
We had an opportunity to resoundingly declare that a man whose campaign is about building walls rather than bridges is un-American, and that banning individuals on the basis of their religious affiliation defies the basic principles for which we stand.
 
We had an opportunity to defeat the most dangerous demagogue to receive a major party nomination in modern United States history.
 
We had an opportunity to take a much-needed stand for the higher principles of justice, fairness, and equality, the fundamental tenets of the Constitution of the United States, and the very notion that America does better when we work to lift one another up from hardship and expand opportunity.
 
We had an opportunity to affirm that our self-worth is not determined by the color of our skin, our gender, to which god we pray, or who we love. 
​
We had an opportunity to provide an example for the women and young girls of our nation that with enough hard work and determination, they can be anything to which they set their minds, even President of the United States.
 
We had an opportunity to elect the most deeply and broadly qualified person to receive a major party nomination, and to affirm the seemingly basic principle that competence is an important dimension of governance.
 
We had an opportunity to move America forward on healthcare, climate change, reproductive rights, the economy, and the Supreme Court.
 
We squandered this opportunity, and in doing so, we failed ourselves.  
 
Shame on us. 

​There is little that is positive that can be said about the current election cycle, especially that of the Republican nominee. What was already a negative campaign cycle – laced with racism, homophobia, xenophobia, and misogyny – was made all the worse with the now infamous tape of him from Access Hollywood, in which Mr. Trump boasted about his celebrity stature enabling him to engage in nonconsensual sexual activity with women.
 
The second presidential debate offered Mr. Trump an opportunity to clarify whether what he boasted about was inappropriate but only talk, or whether he had acted on those views. After being pushed on this point several times by the moderator Anderson Cooper, he said that he had not.
 
This triggered a number of women to come forward publicly in their effort to set the record straight. While a number of prominent Republicans rescinded their endorsements – perhaps most notably Senator John McCain – with Speaker Paul Ryan and others not formally rescinding endorsements but declaring no intention to campaign on behalf of Mr. Trump, some surrogates continue to maintain that the comments in the tape were “locker room talk” and question the motives of these women given the timing.
 
At least two things have been raised in the discussion here, that bear emphasis.

1. There were questions as to the timing of the accusers coming forward this late in the campaign. The explanation has been that in the aftermath of the tape revelation as well as frustration with regard to Mr. Trump’s insisting that he had not acted on his abhorrent comments, thus creating an impetus to speak out.
2. There were further questions as to the legitimacy of claims with regard to quite old claims of sexual assault. Corey Lewandowski and others raised numerous questions as to why they would not have spoken out much sooner, such as shortly after the assaults. This was in many times a point made in conjunction with allegations that the claims were either politically motivated or else for fifteen minutes of fame.

 
This does an immense disservice to all women who have experienced rape and other forms of sexual assault, which is already one of the least reported crimes. And it is not difficult to understand why many would not want to discuss their assaults:
 
It is deeply personal and for many, embarrassing.
 
They may continue to blame themselves for the event based on how much they drank or what they wore. 

It involves someone exploiting a position of power, and in the aftermath of that assault one may feel devoid of the ability to reclaim control.
 
They may fear that they will not be believed.
 
They may not want to acknowledge how vulnerable a position they were placed in.
 
They may want to forget about the event because recounting the details may feel triggering and retraumatizing.
 
To spend time detailing one’s sexual assault, and on national television no less, is emotionally grueling. It involves recounting each painful and deeply personal detail to support the legitimacy of one’s claim. Those who do come forward often take a long time to do so. To allege that taking time to report an assault makes a claim less than legitimate is to not understand rape, assault, or harassment, and it is this deep ignorance that has been in full force since the revelation of the Access Hollywood tape and the subsequent allegations that he acted on his words. 

Mr. Trump’s surrogates have leaped to defend their candidate to the point of questioning the motives of these women (not to mention refuting one of the allegations with a clearly false story crafted in the New York Post), and in doing so highlight the very reason why women are reluctant. Having such public questioning of the legitimacy of these women’s allegations on the national stage could potentially have egregious consequences for further hesitancy regarding coming forward with their own claims. And when people are aware that crimes will likely go unreported, there sadly is more freedom to perpetuate such assault and harassment.
 
Mr. Trump may be shifting from fame to infamy, but should not drag the conversation even further to reduce the already too-rare reporting of sexual assaults.  

In the immediate aftermath of the release of the now infamous tape in which Mr. Trump bragged about celebrity status giving him license to grab women by their genitals and do what he wanted with them -- in many ways just confirming other accounts of his objectification of women but perhaps more striking when seeing the video footage itself -- author Kelly Oxford sent out a tweet that read simply: "Women: tweet me your first assaults," and she included hers.  

Within hours, she was receiving 50 responses per minute. By Monday, she had received 27 million. (Based on when I tweeted mine, it was probably around the 15 million mark). 

If 27 million tweets of FIRST assaults -- and this is just people on Twitter who are aware of this -- doesn't hit home the magnitude of those who would be personally and deeply moved by the callousness of the Trump tape, I don't know what will. And this is in addition to those men who reminded us that they have wives and daughters, thus bolstering their explanation of why they would care about predatory behavior that violates the law and is aimed at 51% of the population (not to mention a subset of the population that votes in large numbers).

The subject of Mr. Trump's mental health has been discussed, admittedly in violation of the "Goldwater Rule." Therapists more recently have begun to weigh in on the mental health impacts of this election -- the negativity, the cynicism, the blame, the hostility, the fear. Now in the mix is the aspect of triggering trauma histories made sadly more salient by Mr. Trump's casual admission of being a feckless thug with no respect for women, and perhaps more sadly the willingness of his surrogates Rudy Giuliani, Jeff Sessions, and Scott Baio to come to his defense, calling it "locker room talk" that was not assault, and Baio even going to far as to fell Fox News viewers to "grow up and get over it." To hear the former mayor of New York City not only dismiss the language as locker room talk but to joke about it is horrifying even in this election, especially given conservatives' purported support for family values. (For the record, professional athletes in the NFL ("we never had anyone say anything as foul and demeaning as you did on that tape"), NBA, and beyond have done their part to show that advocacy of sexual assault is not a feature in their locker rooms, nor would it hypothetically be accepted). Of course, there is irony in the fact that the candidate who joked about sexual assault, when asked by his party to step down as the Republican nominee, insisted "no means no." A little late on that lesson, Donald.

These have not been comfortable subjects for anyone. No sane person enjoys watching this tape. But having a history of sexual trauma -- which applies to far too many – makes it all the more difficult to hear about sexual predation left, right, and center in the news and social media, whether triggering actual flashbacks or otherwise unpleasant memories, potentially stirring depressive symptoms (which Secretary Clinton’s healthcare plan will at least treat comprehensively). Whether visible outwardly or not, sexual assault's impact on the person -- as well as those around them -- is lasting, leading to higher rates of depression, PTSD, substance abuse, and even suicide. The news provides a constant reminder of something that strikes a nerve with respect to an issue that may still feel acute. For those who have been private about their experiences, there is the question of whether to share one's story -- as in the Twitter collection, or among acquaintances -- to reflect on recent events in a productive dialogue about the proper boundaries of sexual conduct, or to maintain privacy (and the emotions that that brings up). And aptly, the organization End Rape on Campus tweeted on Friday upon the release of the tape, the message, "To those affected by the damaging rhetoric issued by Mr. Trump in the video released today -- we stand with you, we hear you, we support you." 

There is the legitimate fear of physical and emotional harm caused by the normalization of "locker room talk" (or worse, acting on it as Trump has been alleged to have) akin to the misguided notion that "boys will be boys" in the context of date rape. When people accept misbehavior -- or worse, assault -- in public discourse and behavior, we facilitate its perpetuation and dampen the vigilance with which we assert our rights as human beings deserving of respect. Please, let us not conflate how men talk in locker rooms with how some bad men may talk in locker rooms. 

They (we) then got to see sexual assault allegations made a spectacle of with a photo op leading into the second presidential debate from the same person dismissing his own taped remarks as locker room banter (note: without evidence of actually spending time in locker rooms himself) and as part of a cheap ploy transparently aimed at rattling his opponent (who actually does argue that women's rights are human rights). 

​Hearing what may have sounded like a familiar experience of unwanted contact (even rape) simply excused -- and in a presidential candidate, no less -- seemingly mocks and disregards the immense emotional impact that it has on the person, whose control was taken from them in a deeply personal way. Experiencing such events at all is more than one should have to endure. Having to defend their status as assaults is abhorrent. And worst of all, it facilitates far too many future opportunities to relive these sorts of experiences when we normalize in the public discourse sexist language and patently illegal behavior amid a marked number of sexual assaults on college campus and beyond. 
 
And it has already happened, with a man at Mr. Trump’s recent rally photographed wearing a shirt reading “She’s a Cunt, Vote for Trump.” Apart from the bad effort at rhyming, the negativity toward women – and the acceptance of transparent misogyny in the public sphere – can have distressingly boundless consequences. The issue is not political correctness for the sake of political correctness. It is moral decency that transcends party identification, and certainly transcends the aesthetics of one’s body, on which Mr. Trump appears to be creepily fixated.
​
No one is perfect, despite Mr. Trump's assertion that he himself is perfect and devoid of faults. Presidents are human, and humans are allowed to make mistakes. But we are also allowed to hold them to higher standards than we do ordinary Americans because they are meant to serve as positive examples for our citizenry and for other nations of the world. (Though to be sure, this behavior would not be accepted in our neighbors either). That we have not only shifted in our campaign season the discussion to an issue that is deeply painful for many to discuss -- with many dismissing the impact and legitimacy of such language and actions -- but creating a culture of violence against women in which we are all the more vulnerable to its greater perpetuation and acceptance.

We deserve better, as women and more importantly, as human beings. We need to prove it on November 8.  

If Donald Trump's healthcare "plan" is to be nicknamed "Trumpcare," it seems to have forgotten about the "care" part. ​

The New York Times rightly noted recently in an editorial that healthcare deserves a more prominent place in the 2016 presidential election than it thus far has earned. Donald Trump’s main argument has been the repeal of the Affordable Care Act (“Obamacare”), though precious little attention has been paid to determining with what it might be replaced. Even more strikingly, the Gary Johnson/Bill Weld website’s “issues” section, while taking time to discuss internet freedom and the war on drugs, has literally no mention of healthcare.
 
The centerpiece of course is the repeal of the ACA, whereas Hillary Clinton seeks further expansion of the ACA and the reduction of premiums by providing families a tax credit to pay for insurance. The Washington Post recently evaluated that while 9.6 million could gain insurance under Clinton, over 20 million could lose insurance under Trump. Moreover, among those not losing health insurance, premiums were projected to go up from $3,200 to $4,700 a year.

Trump’s stated position holds that they stand for the repeal of the ACA, allowing the selling of health insurance across state lines, allowing individuals to fully deduct health insurance premium payments from their tax returns, allowing individuals to use Health Savings Accounts, requiring price transparency from healthcare providers, giving states more autonomy over Medicaid provision, and removing barriers to entry into free markets for drug providers for reliable and cheaper alternatives.
 
A few points. A number of health insurance plans already offer the option of Health Savings Accounts and whether people opt in or out of them is consumers’ prerogative. Thus, this would not be a change from the status quo. Researchers have already shown in a number of contexts that Medicaid expansion produces a number of health benefits such that those states opting out of expansion are left out with more adverse health consequences. Moreover, the block grant allocation may not be sufficient to continue to support the healthcare benefits that they have gained under the ACA’s Medicaid expansion for the poor. Price transparency is all well and good, though few details are specified as to how it would be provided for. Some tools have already been in place, with Fair Health Consumer’s medical cost directory allowing one to search for the price of a procedure or office visit by zip code, though price comparing across hospitals within a region is not necessarily an easy task for the average consumer, particularly if sick and in need of care. And while allowing for international prescription drug importation may help to curb prescription drug prices, there are the additional regulatory barrier which is that they presumably must still meet FDA standards.

At least as crucially is the fact that Trump's plan does not include provisions to protect people from being denied health insurance due to preexisting conditions. While the New England Journal of Medicine recently published a discussion of the importance of addressing high-need high-cost patients -- with 5% of patients accounting for 50% of the nation's healthcare spending -- having multiple chronic conditions is indeed quite prevalent, with higher rates among the poor and elderly. Indeed, in 2014 at the national level, 30.1% of Americans identified by CMS had 2 or 3 chronic conditions, 20.9% had 4 or 5 chronic conditions, and 14.5% had 6 or more conditions. (Not too surprisingly, the rates of multiple chronic conditions is higher among those who are lower income, such that the challenges in obtaining care due to preexisting condition status only exacerbates the already marked health disparities that persist in the United States). These high rates would constitute grounds for insurance denials of millions of Americans in need of coverage for basic primary care as well as specialty care, with access to good preventive care being valuable to avoiding more costly hospitalizations and procedures. It pays to invest in good healthcare, but giving people the opportunity access coverage is an essential first step (whether through the ACA or not) that Trump's plan unfortunately does not ensure. 
 
There is little question that the implementation of the ACA has not gone according to plan and has not been a dream scenario for its more vociferous advocates, particularly amid news of continued insurer withdrawals from markets due to financial losses, the projections of increasing premium rates in 2017, and the limited choice of marketplace providers for consumers in many parts of the country (with 17% of consumers having only one insurance carrier in their region). Yet the rate of uninsured Americans hit a historic low of 9.1% (declining from 10.4% in 2014), with reductions in uninsured rates seen across nearly all age, race, and income groups. While millions of Americans continue to struggle with underinsurance – that is, facing high deductibles and other large out-of-pocket costs that absorb far too much of their income – there is little doubt that having some coverage is preferable to no coverage, and that people are newly getting access to life-saving primary care and thus diagnoses for conditions with which they may have already have been struggling. Indeed, diabetes diagnoses went up in those states that opted for Medicaid expansion under the Affordable Care Act, confirming other findings that those benefiting from Medicaid expansions were more likely to see a physician or go to the hospital for medical care. And investments in good primary care and having healthier patient pools, thus obviating the need for more advanced and expensive medical treatments, can help to control premiums.
 
This is not to say that there are not problems with the ACA’s implementation. To be sure, premium increases adversely affect millions, vastly outpacing increases in income, as do the sometimes exorbitant prescription drug prices (highlighted most notoriously recently in the case of EpiPens). But these problems call attention to the need for things to be fixed, not done away with.  While a single-payer program would address many of the challenges that we face currently with the business model of healthcare provision in the states – a business model that allows healthcare profit motives to trump the human aspects of health – it is not politically feasible in the current climate of divided government and polarization. Addressing the challenges healthcare pricing and access must be within the confines of the contemporary healthcare apparatus that is the Affordable Care Act.
 
“Trumpcare” would too quickly downplay the operative word of “care,” at least for lower and middle class Americans.
 
The ACA needs salvaging and expansion, not repeal. (RAND provided an economic analysis of the Clinton and Trump plans, analyzed here at The Commonwealth Fun). 

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.

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. 

​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.  

​I don’t want to need it.
 
That is a thought that has been all too familiar to me when I venture on the patient side of health care, an industry that I study as a scholar as well with the distance of one investigating a foreign land in which they do not intend to become entrenched.
 
It is a thought that has been all too familiar as I see added to my daily regimen new medications, some of which I trust, others of which I am skeptical after reading reports on the industries that brought them to the market. I am, after all, familiar with the pharmaceutical industry and, while well aware that many have been able to manage well their conditions thanks to their products, am also not without cynicism as to their profit-based motivations.
 
“I don’t want to need it,” is not a mature response to a debacle. It does not remedy the need, nor does it even truly acknowledge the need. It merely resents the medical treatment, the need of which remains in doubt. What it does not ignore is the problem, and the prescription for its solution, whether that prescription is proper or not.
 
I have been on countless medications over the last five years. What has surprised me more than the prescriptions for various medications – some of which I had never heard of previously, and others of which I had heard of through direct-to-consumer ads, which I dislike on principle – is the business aspect of these pharmaceutical companies with which I have been confronted in a way that I have seen discussed precious little: copay savings cards.
 
I was pleased at first. My otherwise $300 sleeping medication got promptly knocked down to $30, which almost made me forget that this particular doctor seemed to engage quite frequently with representatives from the pharmaceutical company pushing the drug. Almost, but not quite.
 
A couple of months later, a new medication got added to the mix to address a chronic parathyroid disorder. When seeing the price of $80 show up (post-insurance) on the pharmacy website made me wince, I did some research on the company website and other sources to weigh the (literal) costs and benefits of the medication. Lo and behold, the distributor Amgen provided a prescription savings card that knocked the price from $80 to $5. For $5, I’ll take my chances with the medication and see if it works for me.
 
Some research confirmed that these savings cards are not totally anomalous, and I have encountered them – sometimes in advance of filling prescriptions, and alas sometimes after the fact – with respect to other medications prescribed to me. And while it is normatively desirable to curb the rising costs of prescription drugs, what is striking about these savings cards is the limited information as to their very existence. My doctors did not point me in this direction. Nor did the pharmacist at Walgreens. I don’t expect that their failure to do so was in any way nefarious – they get no benefit from my paying $5 versus $80 per month – but it is unfortunate that their use depends on the patient being fastidious in their research prior to filling a new prescription.
 
Such an assumption may not be met given many individuals’ trust in, and deference toward doctors’ decisionmaking, with 70% of  Gallup survey respondents confident in the accuracy of their doctor’s medical advice and only 29% viewing it necessary to do their own research (though some research does support a decline in the public’s trust in physicians). Moreover, within this field in which there is ample information asymmetry – with the general public typically not as familiar (or for that matter, capable of becoming so) with the specifics of the medical decisionmaking (see, e.g., Arrow 1963) and potentially unlikely to research the cost-benefit analysis of prescription drugs and other medical treatments. The (even more) cynical part of me is left wondering whether prescription drug companies price their drugs higher than necessary to account for the use of such savings cards, akin to accounting for future "sales" in regular product pricing.
 
There is the additional concern that those who are engaging in that research are not the ones most in need of prescription savings. If – as I strongly suspect – those who do conduct their own research on medical treatments are those who are more highly educated and, relatedly, higher on the income ladder, then benefits are not being distributed appropriately. Sure, people of all income levels enjoy their tax breaks. But those who need the money are not those of higher socioeconomic status, but rather those living paycheck to paycheck and for whom the price of prescription drugs impacts adherence to medication regimens.  
 
Indeed, 20-30% of medication prescriptions are never filled, and 50% of medication prescriptions are not continued as prescribed, with medication adherence dropping after the first six months of following a given regimen. I am the first to confess that I contribute toward these numbers, partly out of frustration of several-times-a-day reminders of a need that I resent, and often out of financial concerns that trump medical concerns.
 
To be clear, these figures are not all attributable to prescription drug costs. Some may be attributable to skepticism, denial about the need for a given treatment, or a frustration with particular side effects that accompany the given drug. But it is difficult to imagine that prescription drug costs are a negligible contributor toward these numbers, which is particularly distressing given that non-adherence carries an economic cost of an estimated $100 to 249 billion annually as of 2009, while improved self-management of chronic diseases is estimated as having a 1:10 cost to savings ratio. It can literally pay to better incentivize adherence (at least setting aside the many questions as to whether we are being systematically over-treated in the American healthcare system).
 
That drug manufacturers provide greater savings to patients is doubtless advantageous in making it more feasible to treat illnesses without causing as much financial burden. As someone at the relatively unusual intersection of high education and relatively low income (lucky me), I am also, I suspect, at the relatively unusual intersection of conducting extensive medical research and benefiting immensely from any financial savings that come my way as a result. But were I less skeptical about the industry with which I interact all-too-much, I would not know that I could reap this reward.
 
It is unclear whether it is nefariously intentional on the part of prescription drug manufacturers that such savings be more in theory than in practice, relying on unrealistic expectations of consumers to do their own research on the medical and financial costs and benefits that they can expect, or whether this is simply a problem of information dissemination (or rather, lack thereof). To be sure, drug manufacturers stand to gain through their use relative to the financial losses incurred from consumers’ shifts to generic drugs instead. But physicians whose patients’ progress is monitored, and as the numbers above suggest, the American economy as a whole, all stand to gain as well. Increasing physician awareness of, and communication about, copay savings for prescription drugs will go a long way toward reducing reliance on consumers’ own savviness to do so, and in turn enhancing adherence to treatments prescribed. 

Depression is widely cited as a leading cause of disability in the United States and around the globe. While in 1990, the Global Burden of Disease (GBD) study cited depression as being the fourth leading cause of disease burden worldwide, in 2000 depression rose to prominence as the third cause of disease burden, and in 2010 ranked second. Moreover, in addition to affecting millions, it has recently been highlighted as especially salient in such high-powered professions as medicine, in which residents often face burnout and depression and rarely seek assistance.
 
Despite the prevalence of recent calls to invest more in mental health research and services, the extent of funding over recent years has remained virtually constant: according to the Kaiser Family Foundation, the mental health per capita expenditure (in millions) at the national level was $122.9 in 2009, $120.56 in 2010, $123.93 in 2011, $124.99 in 2012, and $119.62 in 2013. Indeed, in 18 states, the per capita mental health expenditures declined between 2012 and 2013. See more.