Those words were especially chilling to those who are Muslim or immigrants, both groups against whom Mr. Trump has lodged especially virulent attacks. But in the aftermath of Mr. Trump’s election upset, there are many reasons to ask who indeed does have a place in Trump’s America.
Among those seemingly left behind in Trump’s America are the many millions who struggle with mental illness.
This is far from a small problem. Indeed, approximately one in five American adults (48.5 million) experience mental illness in a given year, with one in 25 American adults (10 million) experiencing a severe mental disorder that substantially interferes with their life activities. An additional 21.4% of American teens experience mental illness. Such conditions can have the capacity to exacerbate physical conditions — whether from anxiety exacerbating high blood pressure or leading to less vigilant maintenance of chronic conditions — and can impede ability to maintain full productivity in work, thus leading to further vulnerabilities with respect to financial security and potentially needing to go on disability. Indeed, serious mental illness alone costs Americans $193.2 billion in lost earnings per year. The most serious consequence of untreated mental illness is suicide.
There are, to be sure, some cases of severe mental illness for which this will not be avoided, or easily avoided due to the need for considerably more intensive treatment. But for many, these adverse outcomes can be moderated with increasing access to quality and affordable treatment options.
Both for reasons of sigma and lack of access (both regarding a shortage of clinicians and a difficulty affording care), only 41% of American adults who have a diagnosed mental illness receive treatment, with only 62.9% of those with serious mental illness receiving treatment and only 50.6% of children with mental illness receiving treatment. And unsurprisingly, white Americans receive those services at much higher rates than do minorities.
Among other aspects of the Affordable Care Act, which delivered health insurance to an additional 20 million Americans and brought the insured rate to a historic low, the Act delivered a massive expansion of mental health benefits. The Act required that most individual and and small employer group health plans, and all plans offered through the Health Insurance Marketplace, offer insurance coverage for mental health and substance use disorder treatment services. Thus, not only were non-marketplace plan benefits expanded to ensure better treatment for these sets of conditions, but the millions who obtained coverage through the ACA marketplace obtained new behavioral health benefits of which they were not previously recipients.
While Mr. Trump had initially expressed an interest in salvaging some more favorable aspects of the Affordable Care Act — namely, protecting people against insurance denials due to preexisting conditions and allowing people to stay on their parents’ health insurance plans until the age of 26, not only is the former goal virtually infeasible absent the insurance mandate so as to broaden the risk pool of insured patients, but Mr. Trump’s nominee for the Secretary of Health and Human Services, Tom Price, is one of the most virulent opponents of the ACA.
While it is not entirely clear with what, if anything, the Affordable Care Act will be replaced as the GOP meanders from “repeal and replace” to “repeal and delay,” what is clear is that neither Speaker Ryan nor Representative Price’s plans would guard against insurers charging markedly higher premiums for those with preexisting conditions, which depression and anxiety would both constitute. Whether or not they officially allow insurers to deny due to preexisting conditions or simply allow for insurance rates to vary as a consequence of those conditions, given the economic realities faced by many Americans — and in particular those Americans struggling with mental illness — they may ultimately prove to be observationally equivalent.
Moreover, with Price’s refundable tax credits allocated based on age group rather than income, no effort will be made to aid those who are lower income (though potentially not so low-income as to qualify for Medicaid (the future of which is also in question) and young or middle-aged and in need of aid to afford their coverage for their physical and behavioral healthcare. The justification is that premiums are determined on the basis of age, with older patients expected to have higher healthcare costs, though to be sure a more fitting allocation would incorporate both age and income into the tax credit schedule. Yet studies evaluating mood, anxiety, psychotic, and substance use disorders found that the average age of onset was typically in teens and twenties, the age groups receiving the least in the way of tax credit aid under Price’s plan.
Those who have reaped the mental health benefits under the Affordable Care Act’s mental healthcare expansion will thus be penalized upon the Act’s repeal and ill-equipped to afford alternatives absent nearly adequate government-provided assistance. (This is of course true of all physical health conditions, on which I am not focusing in this piece). And given the association between mental illness and income — with those diagnosed with Axis I and Axis II mental disorders typically lower income — those affected will have fewer options for obtaining treatment absent insurance coverage (which was already in need of expansion not rescission).
Intelligent and well-meaning people disagree over the proper scope of government intervention in delivering programs, as opposed to relying on market-based alternatives. It is a given — one might even say, a virtue — of living in a pluralistic society. Yet in these literal life and death scenarios — when one is unable to obtain needed care for crippling and potentially life-threatening depression or addiction (not to mention the associated physical problems that result), blind ideology must be tempered in favor of rationality.
Despite his own medical expertise — and in a setting in which he saw first-hand the access to care that those on Medicare and Medicaid were able obtain when they would not otherwise — Mr. Price’s strident partisanship is sure to undermine the quality and access to physical and mental health care on which millions of Americans rely for their safety and wellbeing.