Donald 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.
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.
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.
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]