A recent report from the American Civil Liberties Union and MergerWatch revealed that health care services were being denied by hundreds of hospitals that were religiously-affiliated, such as with respect to abortion (whether providing those services or transferring patients to another hospital that would provide such care), end-of-life care, and the like. This issue is on the rise, as the report notes a 22% increase from 2001-16 in acute care facilities being Catholic owned or affiliated, with five states having over 40% of acute care beds operating under Catholic hospitals (and in turn, related health restrictions). Overall, one in six American hospitals operates consistent with Catholic religious rules, which is admittedly consistent with the share of Americans who identify as Catholic (20.8% in 2015, according to Pew) but does not necessarily afford an individual in a particular region the flexibility to pursue treatment at an alternate hospital if services are limited (e.g., in rural areas).

And while physicians may not be privately opposed to providing certain services in the spirit of promoting patient care, they are obligated to follow the practices of the institutions in which they work. Such denials of care resulted in patients being turned away (e.g., for pregnancy complications that would have precluded the fetus surviving) and being in critical condition upon arrival at an alternative hospital should they have been lucky enough to find one. Reports indicate patients whose untreated pregnancy complications led to severe bleeding so as to require blood transfusion, a patient whose water had broken prior to viability and the complications of which led to sepsis and kidney injury requiring dialysis, and a patient whose untreated complications nearly required a hysterectomy. It is important to note that all of the physicians cited in the report were unable to perform the medical treatment that they knew was necessary for the patient, because of the hospital policies (e.g., not inducing an abortion if there is a fetal heartbeat).  

In the context of frustrations over health insurance and debates over claims denials and "medical necessity," we see opposition to the business of medicine compromising physicians' ability to simply apply their best medical judgment in treating their patients. After all, "do no harm" is not so simple: one may benefit from the medicine in terms of survival but may wake up in tens of thousands of dollars in debt that might lead them to regret having sought care in the first place (leading to psychological distress and in turn, slower physical recovery times, ironically leading quite possibly to even greater costs). Here, it is not the business of medicine mediating physicians' judgments and treatments, but rather the religious affiliation and practices of the institutions through which they provide care. Religion is deeply important to many, and strikes at the core of many individuals' sense of values and identity. The Free Exercise Clause recognizes the importance of the United States government in ensuring individuals' ability to worship free of government interference (though of course also maintaining that there not be any government establishment of religion either). And it is well within a patient's right to seek medical care in a hospital that one views as particularly aligned with their values and morals. However, given the potentially important divergences in preferences over family planning and other policies (along with simply respecting the fact that we are a nation of many different faiths as well as those who do not subscribe to any faith), we should think seriously about the problematic implications of people not having alternative avenues for obtaining needed medical services. At the very least, in the spirit of doing no harm, there should be mandated exceptions for health care for the woman when the professional judgment of the treating physician is such that the medical necessity is clear, and not only at the point of death or near death of the woman. 

​On January 26, 2016, the U.S. Preventive Services Task Force issued a report advising that primary care doctors screen all adults for depression. They advised that such screenings can raise awareness of the common and treatable nature of many mental illnesses. This is particularly important given the potentially fatal consequences of untreated depression (with 41,000 Americans committing suicide each year, 90% of which are associated with mental illness according to the Centers for Disease Control and Prevention) as well as the economic impact of costing the United States $210 billion per year (40% of which are related directly to depression specifically, as well as indirect costs such as losses of productivity).
 
Such advisement was in keeping with an already noted trend of primary care doctors – trained as internists – treating many patients for mental illness, with more than a third of patients relying solely on their PCPs for mental health treatment given limited accessibility of care in many regions as well as concerns about stigma.
 
Given both the prevalence of mental illness and the high degree to which physicians outside of psychiatry are treating mental illness directly or incidentally to other medical conditions, it is important to evaluate the ways in which non-psychiatrists treat patients with psychiatric histories. Do they treat medical conditions equally for patients with or without histories of mental illness, or are there intentional or inadvertent practices that discriminate in the management of health conditions?
 
A firsthand account of this was taken up in a 2013 New York Times op-ed, with the author Juliann Garey noting the numerous occasions in which her medical conditions were not treated seriously once the treating physicians noticed her history of bipolar disorder and her medications to treat it. From being given only Tylenol for an ear infection that soon resulted in a ruptured eardrum and permanent hearing loss, to being scolded by her gastroenterologist because of co-existing psychological and stomach problems, she found that the nature of treatment was noticeably poorer once it was revealed to her provider that bipolar disorder was in the mix, a phenomenon referred to as “diagnostic overshadowing.”
 
The term was coined in 1982 to characterize physicians’ potential propensity to attribute physical symptoms to mental disorders, yielding bias in diagnosis in treatment. Thus, if a patient with a depression history is having digestive symptoms, they might be more quickly attributed to stress as opposed to leading to a GI workup. Mild chest pain might be more quickly attributed to anxiety than a cardiac arrhythmia. While the initial instincts may well be accurate in the end, the disparity in treatment quality may be problematic.
 
By and large, I have been immensely fortunate in that despite a history of depression and a complex medical history, both have been treated seriously, with my physicians highly invested in my recovery in both domains and treating my health conditions with dignity and professionalism, often going above and beyond the call of duty. I cannot say enough good things about my primary care provider and the specialists I have had over the years. However, a recent and quite severe experience with this at SSM St. Mary’s Hospital in St. Louis, MO necessitates some further discussion on this matter of discrimination on the basis of mental health from those in whom we trust for our care.
 
Having entered their hospital care by ambulance after severe complications involving psychotropic medications, it was revealed that my previously diagnosed endocrine conditions were acting up at dangerous levels, with electrolyte abnormalities that were worse than in any of my medical workups to date and such electrolyte abnormalities associated with a significant potential for cardiac complications.
 
Despite my having had prior discharge paperwork from only three weeks earlier to attest to their knowledge of my medication list and dosages to manage chronic parathyroid and stomach conditions, they neglected to provide me with my normal medication regimen, even with the increasingly severe electrolyte abnormalities with which I had presented in their emergency department. Multiple conversations with multiple nurses and the attending physician failed to result in their correcting the numerous deficiencies in this regard: one medication would be approved but another not, another medication prescribed for four times daily (calcium carbonate, hardly carrying any addictive properties) authorized for only once daily. What’s more, the attending psychiatrist ordered the discontinuation of all psychotropic medication without ever once informing me of the decision, let alone explaining the rationale. (It is worth nothing that cold turkey discontinuation of one of these medications, Klonopin, is considered to be medically dangerous).
 
To fail to so much as inform a patient as to the medications that they are being prescribed, or from which they are now barred, is an act of unprofessionalism. To justify it on the grounds that the patient has a history of severe depression adds a further dimension to this maltreatment, which is discrimination on the grounds of mental illness (covered by the Americans with Disabilities Act of 1990) not only from primary care medicine but also from psychiatry, the very subspecialty of medicine designed to treat these illnesses. It should thus come as little surprise that I left the hospital with declining electrolytes and more noticeable symptoms given their lackadaisical mode of treatment and diagnostic overshadowing that, if in a patient more critical than I, could have resulted in much more significant complications.
 
While it is perhaps understandable to take with a grain of salt a medical report from a psychiatric patient, particularly one whose condition contains psychotic features or delusional thinking (neither of which typically applies to unipolar depression), prior medical records and prescription records from pharmacies, and the ability to consult with one’s primary care physician should assuage concerns in this regard and should not result in the failure to adequately treat the medical needs of those who have co-occurring medical and psychiatric disorders and move beyond these discriminatory treatment practices.
 
In a perfect world, such a change would be in the interest of all parties – certainly patients, but also for physicians seeking to do their best jobs in treating their patients, depressed or not (though such an approach may admittedly result in more insurance claims). More realistically, practices will be adjusted strategically on the basis of risk aversion with respect to medical malpractice litigation. With any luck, with more primary care physicians involving themselves to some degree in the mental health care of their patients through routine screenings and such, so too will there be increased understanding of mental health among PCPs whose work had not previously focused on such conditions, and with that greater knowledge in treatment, also greater compassion and thoroughness in treating other conditions in those same patients. 

Reported on April 9, 2016, the Commonwealth of Massachusetts ordered that 4 Arbour mental health facilities -- those in Pembroke, Quincy, Westwood and Jamaica Plain, with a combined 363 psychiatric beds -- all owned by Universal Health Services, “urgent patient care and life safety violations.” This is only further and growing evidence of the lack of care with which Universal Health Services continues to provide mental health treatment in its monopoly of care around the nation.  

The Massachusetts Department of Health and Safety is reportedly empowered to halt new admissions to these facilities on the grounds of these egregious safety violations revealed through recent inspections are corrected:

"The state agency did not specify the violations uncovered at the facilities, but Pembroke Hospital has come under fire by state and federal regulators since late August when a 20-year-old patient, Amber Mace, was found dead in her room at the hospital. Mace had been dead for at least two hours and her body was already in “full rigor mortis” before any staffer at the 120-bed hospital took action, according to state investigative reports obtained by The Patriot Ledger from the woman’s family. Pembroke Hospital staff was supposed to check on patients’ well-being and verify signs of life at 15-minute intervals through the night, but the safety checks were done improperly because staff did not actually enter Mace’s room and watch for signs of Mace breathing, according to state reports. The state determined that Pembroke Hospital created a 'dangerous and inhumane' condition for Mace and said the policy and treatment failures could have prevented the young woman from receiving meaningful treatment."

The pervasiveness of such substandard are provided by this organization is becoming increasingly clear, and should not be tolerated by state agencies or by the organization itself. 

In  a recent visit to the emergency room (side note: one of its "frequent flyers" is a wanna-be singer, dabbling in opera it sounded like), it was brought to my attention that while most of the hospital was in-network, the particular division of doctors to which I needed access was not. It was a Saturday night. The insurance company was closed. And the dreaded phrase came up regarding transfer to another in-network hospital when it became clear that a hospital admission would be necessary: "insurance preauthorization required."

It turns out, despite the fact that peoples' propensity to get sick is not exclusive to insurance company business hours, insurance preauthorization often is required for the transfer to another hospital facility, or for certain procedures to take place. This can result in unnecessary delays in obtaining needed care, or being transferred to less reputable facilities that do not carry certain restrictions. 

The Department of Health and Human Services defines insurance preauthorization as follows: "A decision by your health insurer or plan that a health care service, treatment plan, prescription drug or durable medical equipment is medically necessary. Sometimes called prior authorization, prior approval or precertification. Your health insurance or plan may require preauthorization for certain services before you receive them, except in an emergency. Preauthorization isn’t a promise your health insurance or plan will cover the cost." Such requirements can in some cases lead to extensive persuasion by doctors to insurance companies (that is, those who are not medical professionals but on the business end of the deal) that certain procedures, tests, transfers, are medically necessary. Issues of preauthorizations absorbed in 2006 an average of 1.1 hours per week from primary care providers, 13.1 hours per week of primary care nursing staffs, and 5.6 hours per week of primary care clerical staff. While insurance companies are barred from imposing prior authorization rules in the context of emergency care, some issues regarding interfacility transfers still apply, and should it become clear that a battery of tests must be ordered in the near future, a patient nervous about an impending diagnosis and treatment may have a barrage of insurance inquiries awaiting them first. 

The fact is, this is just one of many ways in which we have nominally worked to expand health care insurance coverage while simultaneously making it profoundly difficult for people to actually utilize those benefits. Whether it is a large deductible that one must meet before benefits kick in, a large out-of-pocket maximum such that expenses can continue to aggregate, or a large coinsurance that can lead one to such conditions as asking their doctor to run fewer or less expensive tests, we often find ourselves crafting policies that perhaps work well enough for those wealthy enough to afford the out-of-pocket costs or poor enough to obtain government-sponsored insurance and credits, but with the middle class continuing to get squeezed. The matter of insurance preauthorization is in fact an equalizing force in that it is not about dollar amounts but rather red tape, navigating a complex system that is all the more challenging when medically compromised and potentially from a vulnerable population. And while parity laws are meant to ensure that medical and behavioral health are treated equally with respect to benefits, such laws are notoriously poorly enforced, with "medical necessity" looked upon with greater scrutiny in the behavioral health context, adding an additional barrier to a category of care already inaccessible to far too many Americans.   

There is little question who benefits from this bureaucratic maze: doctors and patients alike are frustrated if not maddened by the system, and insurance companies themselves are the lone stakeholders gaining from the system. In an election season filled already with so many surprises, one certainty is that health care will remain prominent on the agenda -- whether expanding but building more incrementally on the Affordable Care Act, moving to single-payer, or rolling back the ACA -- and one hope is that with this continued discussion, there should be greater emphasis on allowing questions of "medical necessity" and the timeliness with which those medical procedures be carried out be determined by those holding the medical credentials. 

If there's anything that you take away from reading my blog, I hope that the importance of persisting underinsurance in America is one of them. Chelsea Clinton recently spoke out about this, raising the possibility that Hillary Clinton might use the tool of executive order to help curb healthcare costs for those who are unable to afford to use their health care, specifically working to reduce out-of-pocket maximums: "And, kind of figuring out whether she could do that through executive action, or she would need to do that through tax credits working with Congress. She thinks either of those will help slove the challenge of kind of the crushing costs that still exist for too many people, who even are part of the Affordable Care Act and buying insurance." This was consistent with Clinton's health reform plan in the 1990s, though that we know to have been unsuccessful.  

This raises an important question: What is the best way for a president to achieve this end consistent with the party platform and campaign goals (not to mention many public preferences)? There are a number of options. One is to work with Congress to push for amendments to the Affordable Care Act (ACA) in ways that reduce healthcare costs. The challenge here is that both chambers of Congress are controlled by the Republican Party. It is unlikely that the partisan control of the House of Representatives will change with the November elections. The Democrats have a chance at reclaiming the Senate, but it's a toss-up -- the Democrats may take the Senate, but it may only see a leftward lean in the Senate median with a de facto need for supermajoritarian support in order to pass legislation of any significance. And amendments to the Affordable Care Act would absolutely fit the bill. The result is that there will be a political environment not ripe for major policy change, with potentially only incremental progress to be expected given tendencies toward obstructionism. In fact, partisan voting extends even to non-political but also to procedural votes. In short, Congress isn't likely to move much unless the Democrats take the Senate, and even then there will be marked potential for opposition obstruction. 

Another option is to work with states to incentivize improving upon the federal plan. For example, we find marked variation in air and water quality standards in the states, with California standards being particularly higher. We might envision states opting into add-on plans that cap out-of-pocket maximums and deductibles, two of the plan costs that constitute massive barriers to individuals being able to use the plans by which they nominally are covered. 

Which then brings us to changing health policy by way of executive order, which are legally binding orders given by the President of the United States. The challenge is that the public's view of executive orders tend to low, as Reeves and Rogowski (2015) show. They find that support for the use of executive orders tracks the public's evaluation of the president and the their beliefs in the rule of law (e.g., ensuring civil rights, civil liberties, mechanisms of accountability, etc.). 

So there is a real risk in pursuing policy through this means. When the president works with Congress to achieve progress toward healthcare progress, in the face of obstruction, it becomes relatively easy to point to Congress (in particular, congressional Republicans) as the culprit in precluding movement from the status quo. We are seeing this in the context of the current battle to fill the Supreme Court vacancy held by the late Justice Antonin Scalia. That said, it is easy also for Republicans to say, "You elected Clinton, and what has she accomplished? Vote for us in 2020 and we'll let you decide how you spend your money." But amid a polarized setting, pursuing policy change by way of executive order may be smart, but it would have to work given that there would, in that case, be only one person to blame, using a tool not revered by the American public on principal (a trend that is consistent over time, though with public support for unilateral action higher in those contexts in which Congress fails to act). How Clinton continues this discussion with respect to executive orders (in this context and others) will give us valuable information as to how we can expect her to work with Congress and to what extent she will work toward a stronger presidency, albeit toward responsiveness to public needs by way of unilateral action. 

​On March 12, 2016, Hillary Clinton said of Sanders at a campaign rally in Saint Louis, “I always get a little chuckle when I hear my opponent talking about doing it. Well, I don’t know where he was when I was trying to get health care in ’93 and ’94, standing up against the insurance companies, standing up against the drug companies.” Thanks to the depth and breadth of political records, we know that Sanders was not with Clinton during this battle, but rather ​was continuing to advocate for a single-payer, universal health care system.
 
To be clear, this was not to say that Sanders was standing back on the health care fight, but rather fighting a different fight. In this case, neither won particularly. Hillary’s Health Security Act garnered 103 cosponsors (Sanders not among then), but Sanders’ fight here represents his continued disconnect from the pragmatic realities that one faces when taking policies from a small state like Vermont to a national context.
 
The fact is, most of liberal Democrats would be thrilled to see the passage of a single-payer, universal health care system that is more emblematic of what we see in parts of Europe. Of course, the advantage of many European countries is their size: granting greater benefits with greater efficiency is easier with a more finite population than the United States has. And at the end of the day, pragmatism isn’t just an advantage at the negotiation table – it’s a necessity of governance (not to mention election to get in the door in the first place).  
 
Were it not for the candidates both fighting for the Democratic nomination, they would be on the same team. They share a commitment to expanding health coverage for more Americans and making it easier to draw on the coverage that they have, with one candidate espousing the more realistic vision in a conflictual partisan environment and the other putting forth more liberal ideals whose implementation are less realistic. The problem is that if you ask for too much, you may get nothing. If you make a realistic request, you’ll probably get something. And that something will make the difference in who is able to see their doctor about a suspicious lump that could be malignant, for an endoscopy to rule out gastric cancers, for therapy that can help one to manage depression before it leads to suicidality and medical disability.
 
What we also know is that pragmatism isn’t sexy in an election season. There are times when Hillary comes off like the parent constantly having to tell her children “no” to their lofty goals, even though she is most often right. Her plan is the stuff of one who has weathered many storms and knows what can (and must) be done: expand the Affordable Care Act, reduce rising out-of-pocket costs for obtaining medical treatment, crack down on rising prescription drug costs, and protect reproductive choice. These are not game-changers, but they are necessities, and her battle scars come with the evidence of her ability to weather this storm.
 
There is something to be said for aspiring to greatness, and in the absence of those aspirations to greatness it becomes unlikely to achieve it. Indeed, one of the great political inspirations of the Democratic Party, Bobby Kennedy, held famously, “Some people see things as they are and say, ‘Why?’ I dream of things that never were and say, ‘Why not?’” Indeed, we should with more frequency be asking ourselves “why not?” and to Sanders’ credit, he is pushing for more of that discussion. The problem is when it interferes with the ability to achieve good governance in the face of a party working to undo all of the progress on which Clinton and Sanders both hope to build. Clinton has both the tools and the wisdom to deliver when we most need it. 

On Monday, March 14, I woke up in the ICU after having been intubated for reasons that I won’t go into. The presenting problem had more to do with my chronic depression, but the subsequent lab work revealed massive electrolyte imbalances that could easily have induced seizures or a coma in someone not as chronically predisposed to them as I. Because of a history of depression that was the “main event” in the conversation, I was discharged with worse levels than I’d had in years (and for that matter, worse electrolytes than in previous hospitalizations for this issue... personally, I don't think the treatment effect of being surrounded by crucifixes helped).
 
It is not news that many Americans go to their primary care doctors first in seeking treatment for depression and other mental illness, whether because of persistent stigma attached to receiving mental health treatment or because of the greater difficulty access to services given relatively low numbers of providers and a markedly lower rate of providers accepting insurance relative to other medical practitioners.
 
In a sense, it’s all well and good to get that care from anyone – they have gone to medical school, done psychiatry rotations, encountered both medical and psychiatric cases in internal medicine residencies, and presumably continue to be competent physicians addressing a host of different issues (which is not to say that a physician friend in Westchester County doesn’t spent three fourths of his time addressing diabetes and high blood pressure, to which I respond in probabilistic terms given disease rates in the United States).
 
Deemed the “common cold of mental health,” depression leads to approximately 8 million doctors’ appointments a year, again whether because of comfort level or availability or insurance. The catch is that primary care doctors emphasize breadth over depth, whereas specialists are best equipped to address the nuances of more particular care. Thus, there are limitations in the care that even the most well-meaning practitioners can provide.
 
But there is a greater problem here, spanning all physicians and not just those in primary care (PCPs). What those experiencing mental illness – whether depression or anxiety – may well experience psychosomatic symptoms with which many even just having a stressful week can relate (heart palpitations, indigestion, perspiration, headache). The challenge is when we preemptively write off such symptoms in a patient who also happens to have a history of depression, especially considering that a number of those with depression also have medical illnesses as well (sometimes depression triggering worse self-care and thus issues such as type II diabetes, other times chronic illness and pain understandably contributing to depression or its worsening, and still other medical issues such as thyroid problems notoriously having the potential to induce depression in otherwise non-depressed patients. So in short, there are a lot of moving parts that make things both clinically interesting and diagnostically challenging.
 
And that is not necessarily doctors’ fault. Indeed, most are very well-meaning. I for one have been blessed by my doctors at New York Presbyterian. But it is not uncommon to find accounts – some anecdotal, others more systematic – of those with mental illnesses getting short shrift from physicians to whom patients are going for non-psychiatric conditions (whether reluctance to write prescriptions, being suspicious of whether it's "all in their head," etc). And again, there are reasons for those concerns, especially if there are risks of overdose in a depressed patient, even if the particular prescription is indeed valid.

The good news is that there are resources in place to facilitate productive discussions with doctors (of all specialties) about depression and its management. The bad news is that as depression spirals downhill, it becomes more and more difficult to advocate for oneself, and it’s easy to find oneself on the losing end of the battle. When at the lowest point, getting dressed can feel like a challenge in itself. Researching physician quality and medications and scheduling appointments goes beyond arduousness. (And given the noted high rates of depression and suicide among doctors themselves, this is not likely unnoticed by any parties). Having a good mental health provider is imperative if this is something with which you struggle or might be predisposed to struggle (whether from physical illness, a family history, a stressful job, such that a single trigger might be devastating). But having a good primary care provider to advocate when you cannot do so is at least as important, and it’s worth searching for one who doesn’t stigmatize reaching out, and who’s invested in treatment and feels like a safe person to go to if only in the interim until other resources are in place. We have already seen medical recommendations about depression screenings for all patients, which hopefully will reduce the stigma of acknowledging some of the symptoms on that list (that is, you’re not being singled out and asked, “You look tired today. Do you mind filling out this survey about your loss of interest and pleasure?”) and raise greater awareness to doctors of the prevalence of these symptoms in their patient populations, whether or not they meet DSM diagnostic criteria for depression (because as we can draw from pain management, it's easier to manage when caught earlier at a 6 as opposed to an all-consuming 9 or 10 ("but it goes to 11").
 
While doctors are – admittedly with much reason – told that when they hear hoofbeats, they shouldn’t assume zebras. That is, many ordinary diseases are in fact ordinary. But given the complexity and interconnectedness of the mind and the body, and the ways in which they can exacerbate ailments in the other, it is at least important to have more of a “zebra prevention strategy” in place (yes, I come from the San Francisco Bay Area, I have experienced one major earthquake in 1989, and you bet my bookshelves were bolted and I had an earthquake supply kit) so that doctors will  be less likely to write of symptoms as physiological manifestations of depression when there could be something more at work (or to undergo expensive tests instead of making a referral to a therapist). So is the solution to run expensive batteries of tests on a mere hypochondriac? Surely not. But would it hurt is to make more open the discussion across the country (and not just major metropolitan areas where services are more available and information more easily acquired) discussions to disentangle the medical from the psychological, and their potentially numerous interactions? Surely not. 

I am an academic. We are constantly learning. Doctors are constantly learning. The more that we can remind ourselves that yes we have our expertise, but we can also grow and evolve and improve (and that shortcomings in a patient case present opportunities to learn for future reference), the better off both doctors and patients will be. 

​With the 2010 passage of the Affordable Care Act (“Obamacare”), we saw the vast expansion in the number of people who were able to be covered by a health insurance plan. In fact, while the US Census Bureau found that in 2009 (before the enactment of the ACA) the rate of uninsured Americans was 15.7%, compared with 9.2% in 2015, the lowest uninsured rate in 50 years.
 
The problem is, this isn’t enough. Indeed, what we continue to face in large number in the United States is the problem of underinsurance, with people unable to utilize the health insurance benefits covered under their plan. Underinsurance can be defined as having out-of-pocket health care costs excluding premiums over the last year that are at least 10% of one’s household income, or a deductible of at least 5% of income. The Kaiser Family Foundation found that health care deductibles have risen to degrees outpacing wage increases, making clear the strain on working-class individuals and families. In fact, 31 million Americans were underinsured in 2014. This shakes out to being 23% of 19-64 year-old adults covered by an insurance policy. For perspective, 31 million individuals is the equivalent of the entire tri-state area’s population.
 
Consider some basic facts:

• 11% of privately insured adults had a deductible of $3,000 or more in 2014. (This rate was 10% in 2003). 20% have deductibles of $2,000 or more. The average deductible is approximately $1,100 (67% increase over 5 years ago). Thus, the average person will still need to spend approximately $1,100 before their policy will cover care. That alone is over 2% of the average American’s pre-tax income (not including copays and coinsurance).
• 51% of underinsured individuals reported problems with medical bills. 44% reported that costs prevented them from getting needed care.
• While premiums went up 4% between 2014-15, workers’ wages increased only 1.9% during that same period. Premiums for family coverage increased 27% between 2011-2015.
• 1 in 4 adults surveyed by Families USA did not seek needed health care because of cost. Among those with deductibles of $1,500 or more, nearly 30% could not afford needed health care.

 
There are important steps in place to make health care more affordable for those who have limited income. The federal poverty level (FPL) for a single-person household was $11,770/year in 2015, with Medicaid or CHIP available to those making less than 138% of the federal poverty level (up to $16,243/year), out-of-pocket assistance to those making 100-250% of the federal poverty level (up to $29.425/year), and premium tax credits available to those making between 100-400% of the poverty level – that is, up to $47,080/year (however, note that this is in reference to the federal and not the state poverty level, with some regions such as New York City and San Francisco having especially high cost of living).
 
The question then becomes, what if you make $50,000 per year in New York City, where the median apartment rent is $3,100, or in San Francisco, where the median apartment rent is $3,500? Absent an income high enough to shoulder the load of deductibles and medical bills, or low enough to garner greater (or perhaps any) government support, middle class families find themselves caught between a rock and a hard place, often finding themselves skimping on needed health care, and thus potentially making themselves more vulnerable to more serious (and subsequently more expensive) medical conditions down the line. Such reduction in the use of health care policies is particularly poignant when considering that nearly 40% of mortality cases in the United States are estimated to have been from preventable causes of death.
 
It should not come as a surprise that delaying treatment (or even an initial doctor’s appointment) can lead to more costs down the line. A trip to urgent care for an X-ray and splint for a fractured foot may not be cheap, but it’s more economical than surgery if made necessary by further wear and tear. The cost of cancer treatment goes up significantly from stage II to stage III (in the case of breast cancer, going from $17,400 to $32,600), with earlier testing potentially aiding with diagnosis and earlier intervention and better survival rates. If an artery blockage is detected early, angioplasty may be a reasonable intervention, with costs ranging from $44,000-145,000, compared with heart bypass surgery, which can range from $70,000-200,000 or more in cost.
 
Also not surprisingly, given this reduction in medical treatment by those unable to afford it, America has marked income inequality in life expectancy. The rampant income inequality in the United States has been well-documented, with the 2015 Global Wealth Report holding that America is the richest and most unequal country, with the United States having by far the highest share of the total global personal wealth (41.6%) but also the highest concentration of overall wealth in the hands of the few (with a Gini coefficient of 80.56 on a scale of 0-100). What’s more, America’s middle class has been shrinking over the years, with more people moving into lower-income and upper-income groups, and reports have shown that paying rent has been an increasingly difficult challenge for the middle class and not just the poor. In 2010, the average upper-income 50 year-old man would be expected to live to be 89, but if lower-income would be expected to live to 76 (that is, a 13-year differential based on income alone. The same inequality can be seen among women, with a life expectancy of 92 if at the wealthiest end of the spectrum versus 78 on the lowest end of the spectrum. While some of these disparities can be attributed to other factors such as eating (and relatedly, obesity) and smoking habits, it is not difficult to imagine how the reluctance to invest in diagnostic procedures given high deductibles and coinsurance would factor in here in a non-trivial way.     
 
The notion of “the American dream,” has permeated much of our society’s discourse, in particular in presidential election seasons as we hear the candidates’ journeys to their running for office (some from humble beginnings, others less so), and as candidates offer their policy solutions to help individuals to rise up the income ladder through hard work and seizing opportunity, achieving successes of which previous generations only dreamed. The problem is that this dream appears to be more alive and well in nations other than America, while every day working families are expected to pull themselves up by their bootstraps.
 
The 2016 presidential campaign provides an opportunity for underinsurance to be addressed squarely by the candidates. Sanders raised during the March 9, 2016 debate these challenges of affordability in using health insurance and obtaining prescription drugs. Clinton has called attention to the advancements made by the Affordable Care Act and her intention to build upon its successes and expand coverage. The Republican candidates have expressed a determination to dismantle the Affordable Care Act and offer alternatives to curb prices, such as Trump’s proposal to use imported prescription drugs and Rubio’s plan to invest in market-driven alternatives and tax credits.
 
While the realities of governance, particularly amid divided government, are such that the ideals espoused during the campaign season typically ultimately find themselves tempered through partisan compromise with Congress, the months ahead provide a crucial opportunity for citizens to press the candidates on how they will work to close the gap in health care affordability moving forward.  

​While the fight for the Democratic nomination is not over, Hillary Clinton’s commanding victories in South Carolina and on Super Tuesday solidified her support with a number of key Democratic constituencies, and notably winning with those reporting in South Carolina exit polls that they cared most about health care and among those reportedly caring most about income inequality.
 
Battles for party nominations – especially long and protracted battles as in 2008 and 2016 – are often characterized by rhetoric aimed at setting candidates apart from one another in policy substance, experience, and/or ability to execute the given policy vision. Yet there are questions as to how different candidates ultimately are on the issues.
 
In many cases, the answer is that there are far more similarities than not. Indeed, at the heart of much of the Clinton versus Sanders debate is the issue of experience: supporters largely fight for the same issues, but Sanders supporters think in terms of expected benefits, while Clinton supporters think in terms of expected values (that is, both expected benefit and the probability of obtaining that benefit, which in a conflictual partisan environment requires some measure of pragmatism). The Washington Post reported that Senators Clinton and Sanders voted alike 93.1% of the time, with Clinton overall more aligned with the Democratic majority.
 
However, there is a key vote on which they disagreed, which strikes at the heart of the campaigns’ core messages: while Senator Clinton joined 73 other Senators to vote in favor of the Paul Wellstone Mental Health and Addiction Equity Act of 2007, Senator Sanders joined 9 Democrats and 15 Republicans to vote against it.  
 
Hillary Clinton’s emphasis on health care issues has been long-recognized, from her work with the Children’s Defense Fund to her less-than-successful efforts to revamp health care in the 1990s to her advocacy in favor of protecting and expanding on the Affordable Care Act. Sanders likewise has spoken vociferously in favor of expanding the right to health care, advocating for Medicare for all Americans. Both candidates have welcomed the opportunity to talk on the campaign trail about mental health, an issue that affects an estimated 1 in 5 Americans in a given year. So what is this vote that divided them?
 
The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) is aimed centrally at preventing health insurance companies from giving lower benefits for mental health and substance use disorders than for medical or surgical benefits. The issue was raised at a Portsmouth, New Hampshire town hall, with a woman addressing the challenges of navigating insurance coverage for her son’s mental health treatment, to which Clinton asserted her determination to ensure that parity laws are properly enforced.
 
To be sure, Senator Sanders has spoken in favor of protecting coverage to mental health services, though his discussion of mental health only in the context of gun violence in the October 2015 Democratic debate met with mixed responses. Yet when we rely in no small part on candidates’ records in office as evidence in support of the policies that they profess to support as president, this nay vote on the parity legislation is important not just to mental health policy but also to broader issues of underinsurance and income inequality, which has been central to the Sanders message.
 
While parity laws provide that physical health and mental health issues be treated equally by state insurance providers, the laws are inadequately enforced and insurance denials for mental health care remain high amid challenges to “medical necessity.” Despite ample attention to expanding the number of people who are covered by an insurance plan, a pervasive remaining problem is that of underinsurance, which according to the Commonwealth Fund in May 2015 had risen to 31 million Americans, a figure doubled from estimates in 2003. Such individuals, given exceedingly high deductibles, copayments, and coinsurance, are either unable to use their health insurance at all (leading to complications from potentially otherwise treatable conditions) or who face financial despair because of their medical costs. This is all the more prevalent in the context of mental health care, with over 50% of respondents in a 2013 survey citing cost as the reason for not obtaining mental health treatment, even if they had health insurance.
 
There are at least two reasons why this issue of underinsurance is particularly relevant to mental health coverage. First, a recent report found that 72% of American adults feel stressed about money, and that financial stress is among the main issues people cite as a source of stress and depression. Thus, limiting the feasibility of utilizing health services perpetuates the need for drawing on those services, both medical and mental health, with many interactive effects between the two.
 
Second, underinsurance is perhaps most acute within the domain of mental health, with many insurance plans limiting the number of therapy sessions that may be covered for certain conditions, and fewer and fewer psychiatrists seen taking Medicare and private insurance as in-network providers (an estimated 55% in 2015, compared with 93% in other medical specialties). This leaves patients, if they can obtain an appointment, to face potentially arduous reimbursement processes for low reimbursement rates in many cases.  Thus, there is an inextricable link here to the pervasive income inequality of the American economic system, with many most in need of these medical and mental health services unable to obtain them, even irrespective of their having obtained some level of health insurance.
 
For all of the idealistic rhetoric that typically accompanies presidential campaigns, improving the American health care system will not happen overnight. Important first steps toward progress will include tackling the problems of underinsurance in medical and mental health care, and ensuring the enforcement of existing parity legislation, on which the Democratic candidates’ voting records have in at least one key instance diverged. The Sanders campaign would do well to reconcile the inconsistency between this vote and its rhetoric on the trail.