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.