How President Trump will impact US mental health care

Future President Trump // Photo credit: Gage Skidmore [CC BY-SA 3.0 (http://creativecommons.org/licenses/by-sa/3.0)], via Wikimedia CommonsDonald Trump was elected President of the United States yesterday in what has been labeled a stunning upset. While much of the broader social discussion today will focus on how Trump’s victory happened, as psychotherapists we now must consider how President Trump will impact our profession.

Mental health is not mentioned in Trump’s health care reform paper or on the health care page of his campaign web site. So for this post, we look to his other stated policy goals to see how mental health care would be impacted.

Obamacare

On Trump’s website, he has promised that he would work with Congress to “completely repeal Obamacare.” Realistically, Republicans in Congress will need to wrestle with the fact that, while the thing known as Obamacare is unpopular (especially among Republicans), many of its provisions are very popular. Simply repealing those provisions could be politically problematic. So the question becomes this: What will a Republican House and Senate keep from Obamacare, and what will they change?

As it relates to mental health care specifically, Obamacare’s insurance plans currently cover about 20 million Americans. Each person covered by an Obamacare plan has coverage for treatment of mental health and substance abuse issues, though coverage does not necessarily equate to the ability to get care.

If the Trump administration is able to work with Republicans in Congress to pass a law shrinking or eliminating Obamacare, some of those who currently are covered under those plans would instead get health care coverage through an employer or on the individual market. They thus would continue to have at least some level of mental health coverage. Others would likely become uninsured, and would need to pay out of pocket for mental health care.

Health care reform

The other market-based reforms to health care that Trump has suggested, including reducing barriers to the marketplace for drug companies, allowing additional tax deductions, and changing rules around Health Savings Accounts, seem unlikely to have significant direct impact on mental health care.

One suggested change, however, could weaken mental health coverage. Trump has proposed allowing individuals to purchase health insurance across state lines. While federal law now defines mental health care as an essential benefit of group plans, some state parity laws are stronger than others. It is possible that those looking for inexpensive health coverage would shop across state lines for plans with lower premiums — but that those plans would also be based in states with less strict legal requirements for the level of care provided.

Regulation

Trump, like many Republicans, has a generally unfavorable view of government regulation. He has said he wants a moratorium on new federal regulations that are not compelled by Congress or directly related to public safety. If such a moratorium were to be enacted, it would (as one example) make it more difficult for the Department of Health and Human Services to continue clarifying HIPAA through the regulatory process. Mental health providers sometimes benefit from the clarity afforded by these regulations, such as a prior round of HIPAA regulations clarifying the use of unsecured email.

Medicare and Medicaid

Trump has said he wants to make Medicaid into a block grant program, which could give states more flexibility in how they use that federal funding. However, block grants tend to shrink over time. One analysis of 13 major housing, health, and social service federal programs administered through block grants found that all but one of them had shrunk over time when compared to inflation. Some shrunk dramatically. The structure of federal block grants makes it difficult to measure their impact and easier to look to those grants for cost savings, according to the analysis.

For counselors and MFTs, it is hard to say whether a Republican-controlled government would be receptive to their ongoing efforts to become covered providers in Medicare. The up-front costs are off-putting to some legislators, but because MFTs and counselors can provide mental health services at lower reimbursement rates than Psychologists, adding them to the mix could produce long-term savings. The master’s level professions have had some success getting Republicans to co-sponsor legislation that would bring them into the Medicare program.

Stigma

The one place where Trump does talk about mental health care on his campaign web site is when discussing the Second Amendment. There, he says we need to “fix our broken mental health system.” He goes on to suggest that “We must expand treatment programs, and reform the laws to make it easier to take preventive action to save innocent lives.” He acknowledges that most people with mental illness are nonviolent, but says that in recent mass murders, there were red flags that were ignored.

While it is good that Trump acknowledges the need for expanded mental health care, and that the vast majority of those struggling with mental illness are nonviolent, it does not bode well that the only time Trump discusses mental health care is as an alternative to meaningful gun control. Over the past few years, there has been a well-established pattern of Republican politicians similarly using poor mental health care as a scapegoat for gun violence — and then doing nothing to meaningfully improve mental health care.

As you can see, there is a lot yet to be determined about how President Trump and his administration will approach mental health care. While some may be concerned about a lack of clear policy goals related to mental health, this also suggests that the field may have an opportunity to influence what those goals become. In the months ahead, as Cabinet members and other advisors are appointed, it may become clearer what directions Trump and the Congress will take.

Photo credit: Gage Skidmore via Wikimedia Commons [CC BY-SA 3.0]

6 thoughts on “How President Trump will impact US mental health care

  1. From the Trump campaign web site (I think you missed it):

    https://www.donaldjtrump.com/positions/healthcare-reform

    “Finally, we need to reform our mental health programs and institutions in this country. Families, without the ability to get the information needed to help those who are ailing, are too often not given the tools to help their loved ones. There are promising reforms being developed in Congress that should receive bi-partisan support.”

    • Thanks, Dave. I’m not sure whether that appeared on the earlier version of his HCR page — I had been up and down that page looking for mental health discussion — but I could have missed it, and either way, it’s good to know it’s there now. The reference to reforms being developed in Congress may be a reference to the 21st Century Cures Act, which I’ll be writing about separately.

  2. Thanks for this succinct perspective. Do you imagine the dismantling of ACA will also mean a less integrated/collaborative healthcare landscape? Should Medical Family Therapists or other behavioral health specialists working in this context be worried about their “place at the table”?

  3. I am under the impression that the Mental Health Parity Act is separate from the ACA, and thus would not be affected by changes to the ACA. I see parity as the law that more directly impacts the provision of and access to mental health care. Am I correct that parity is separate from the ACA and would have to be specifically targeted in order to change its rules? I’m hopeful that this is the case because it doesn’t seem like something Trump or Congress would want to change because it only benefits consumers.

    • The two are related to a degree. The ACA expanded the reach of prior federal parity law, expanding parity to include plans that had not previously been included in the law’s scope. So, hypothetically, if the ACA were completely repealed, there would still be federal parity law — it just wouldn’t be as strong. (There also are many states with their own parity laws.)

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