Mental health issues have been largely absent from the debates.
The mental health crisis stemming from the loss and isolation of the coronavirus pandemic is not on the agenda for the second and final presidential debate Thursday night, nor is the steadily rising number of people dying by suicide and overdose, nor is the shortage of mental health providers who could have helped them. These issues were ignored almost entirely in the first debate and the following town halls by the moderators and both candidates.
But data is beginning to show the toll of the parallel mental health pandemic. Three times as many adults have had symptoms of an anxiety disorder, depressive disorder or both during the Covid-19 pandemic compared to the first half of 2019, according to surveys by the CDC. In mid-July, four in 10 adults showed signs of a disorder.
Despite the spike, there were only passing references to the treatment of mental illness or substance use. Responding to questions about winning support from Black voters and his role writing the 1994 crime bill, former Vice President Joe Biden briefly mentioned support for hiring more school psychologists, decriminalizing marijuana, diverting drug cases from criminal courts and sending mental health professionals with police on crisis calls during his town hall.
“We just have not seen a lot of conversation around mental health policy leading up to the election,” said Nirmita Panchal, a mental health policy analyst at the Kaiser Family Foundation and co-author of an article comparing the candidates’ proposals.
What Biden and Trump could debate
A debate of the candidates’ mental health plans should start with their overall proposals for health insurance coverage, said Sherry Glied, a professor specializing in mental healthcare policy and the dean of New York University’s graduate school of public service.
“You can have a mental health plan, and it can be as lovely as you'd like it to be. But if people don't have health insurance coverage it isn't going to get you very far,” said Glied, an assistant health secretary in the Obama administration who helped represent the Biden campaign on a task force bridging policy differences with defeated rival Sen. Bernie Sanders. Both candidates have mentioned the Affordable Care Act, with Biden backing President Obama’s signature health care plan and President Trump condemning it. More than 20 million people gained health insurance coverage under Obamacare, including more than 14 million people enrolling in Medicaid.
Glied criticized Trump’s attempts to roll back the Affordable Care Act and his policies allowing states to reduce Medicaid coverage and add work requirements. “If people are getting kicked off Medicaid,” she said, “all the opioid plans you have in the world are not going to do any good.”
Neither the Trump campaign nor Biden campaign provided comment on their mental health plans.
No alternatives to Obamacare’s mental health protections
Most of the recent expansions of mental health coverage came through the ACA. The law made mental healthcare an Essential Health Benefit for many health plans, extended the mandate to equally cover mental and physical health benefits to more types privately managed health plans and required most insurers to cover pre-existing conditions, including serious mental illness. Trump has not proposed replacements for those protections apart from an executive order on pre-existing conditions that has been criticized as vague and unenforceable. If the Supreme Court strikes down the law — which it has the chance to do in its upcoming term — “we would likely see a reduction in coverage for mental health services,” said Panchal.
Another challenge to the expanded mental health coverage comes from cheap short-term insurance plans that do not have to abide by the ACA’s requirements to cover pre-existing conditions or mental healthcare. The Obama administration cut the length of these plans to three months, but in 2018, the Trump administration lengthened the maximum coverage to three years.
Biden has said he will expand and enforce the ACA and the 2008 Mental Health Parity and Addiction Equity Act, which required most types of health plans to equally cover mental and physical health benefits. More than a decade after the parity act was passed, the federal government has failed to stop insurance companies from using some practices that deny or delay mental health services. But Biden “hasn't offered a detailed plan of what [it] would look like” to enforce the law, said Panchal.
Neither candidate offers many details on how they would address the shortage of mental health providers. Trump’s 2021 budget proposes increasing funding for behavioral workforce development to $139 million a year. Biden hopes to double the ranks of school mental health providers such as guidance counselors and psychologists. Whomever wins, their plans will have a lot of detail to fill in if their administration hopes to solve a projected shortage of 12,000 adult psychiatrists in 2030 — a third of the total field. The Health Resources & Service Administration also forecasts a shortage of more than 11,500 addiction counselors, due to increasing demand for their services.
Suicide prevention plans focused on veterans
Trump and Biden have more detailed plans for preventing suicide, which has been increasing steadily for the last two decades. Each focuses their plans on veterans, who die by suicide at a rate 1.5 times higher than non-veterans. For veterans in mental health crises, Biden has proposed hiring more mental health staff for emergency rooms and staffing crisis phone lines so calls aren’t missed. Trump announced a national strategy in June that aims to coordinate research and funding for veterans and the general population among federal, state and local governments as well as universities and nonprofits. His 2021 budget proposes increasing funding for suicide prevention programs at the Department of Veterans Affairs by 30%, and a $3 million increase for SAMHSA grants that would help screen an additional half-million people for risk of suicide. The pandemic emergency CARES Act passed in March adds another $50 million in funding for suicide prevention.
Other groups at higher risk of suicide are given comparatively little attention. Neither Trump’s campaign nor White House website mentions the unique risk of suicide for LGBTQ teens, who are more than three times as likely to attempt suicide than their straight peers. Biden says he will “work to end suicide among young LBGTQ+ individuals” but does not propose any policies that would address the challenge specifically.
If you or someone you know is thinking about suicide, please call the National Suicide Prevention Lifeline at 800-273-TALK (8255) or text the Crisis Text Line at 741-741.
For more information
Kaiser Family Foundation
- COVID-19, Mental Health, and the 2020 Election: A Review of Candidate Platforms
- President Trump’s Record on Health Care: Mental Health and Substance Use
Biden for President – Health Care
President Trump’s Executive Order on An America-First Healthcare Plan
