What the Election of President Trump May Mean for Mental Health Policy

This is part of an ongoing series of posts in which Columbia University Press authors look at the implications of the result of the 2016 presidential election. In this post, Paul Gionfriddo, author of Losing Tim: How Our Health and Education Systems Failed My Son with Schizophrenia, discusses how mental health policy will be affected by a Trump presidency:

What the Election of President Trump May Mean for Mental Health Policy
By Paul Gionfriddo

The election of Donald Trump as President will influence mental health services in America. We just don’t know how.

We have generated significant positive momentum for mental health system reform during the past two years. The federal government has begun to lay a new foundation for a modern, community-based system of mental health services.

This has been no small feat. In the aftermath of the Sandy Hook shootings, federal policymakers initially could come to no consensus about how they should respond. Some argued for more deep-end services for individuals who were a danger to themselves or others. Others wanted stricter gun control laws to keep weapons out of the hands of most people with serious mental health conditions.

The earliest ideas did not consider the bigger picture – that mental illnesses are most frequently diseases of childhood, and seldom manifest in violent or dangerous acts.

Losing Tim helped change those perceptions. Congressman Tim Murphy (R-PA), the leading House proponent of mental health reform legislation, cited the narrative as one of the reasons he changed his approach in the legislation he authored. And Senator Chris Murphy (D-CT) tweeted that his companion Senate proposal was “for the countless people like Tim” who, he argued, deserve a mental health system that works.

My own organization, Mental Health America, made prevention, early intervention, integrated services, and recovery the pillars of our work. We argued that by applying a “danger to self or others” standard as a trigger to treatment for mental illnesses, we made them the only chronic diseases that we wait until Stage 4 to treat – and then often inappropriately through incarceration.

We argued that we needed to act sooner to help children and young adults, and developed a multi-faceted educational campaign promoting early identification and intervention built around the hashtag “B4Stage4.”

The established mental health advocacy community organized itself around a common set of the principles we shared and around the more comprehensive legislative proposals that evolved. The House and Senate bills gained bipartisan traction and momentum. As election day came, we were poised to celebrate the Lame Duck session passage of the most significant federal mental health legislation since President Kennedy signed the Community Mental Health Centers Act back in 1963, and to build on this in 2017.

Now there is a sense of uncertainty about what will come next.

I do not believe that there will be a seismic shift in the mental health policy landscape in the coming years that will undermine the progress we have made.

For one thing, the President-elect experienced the death of his older brother Freddy at the age of 43 from a substance use disorder, and knows first-hand the toll behavioral illnesses take on families. For another, Vice President-elect Mike Pence worked to improve mental health services in his state during his time as Governor of Indiana.

Also, the newly elected Congress looks very much like the Congress that came before it, with many strong proponents of mental health reform remaining in positions of leadership and influence. Finally, the advocacy community was prepared to continue to work together no matter what the election outcome.

Still, there are many issues that surfaced during the campaign that may have a profound effect on people with mental illnesses.

One is the move to amend the Affordable Care Act (ACA).

ACA made mental health benefits “essential health benefits” that had to be covered by all insurers. It also enabled the expansion of Medicaid to support single adults with chronic diseases, including mental illnesses. In requiring insurers to offer coverage despite pre-existing conditions, it also made sure that when children with serious mental illnesses became adults, they did not become uninsured.

President-elect Trump has said that he favors retention of the pre-existing condition provision. But if the essential health benefits are changed or insurers can pay out less for those with pre-existing conditions, it could take the teeth out of that commitment.

President-elect Trump also proposed block-granting Medicaid. This would not be hard, because the federal Medicaid program is already fifty different state Medicaid programs operated under a common set of federal rules. If the payments were bundled and some of those rules were left in place, that could be a good thing.

States might use the flexibility they are granted to innovate to cover housing, employment supports, and peer support services that people with mental illnesses need.

However, if dollars are reduced when they are blocked together – as happened in the 1980s and led in part to the inadequate state systems of care that persist today – then people will get less access to services and supports, not more.

President-elect Trump has also said that he will be “tough on crime.” People in jail and prison are significantly more likely to have mental health and substance use disorders than people who are not incarcerated. If being tough on crime means putting more people with mental illnesses into the criminal justice system, then that would just accelerate the revolving door of hospitalization, frequent incarceration, and chronic homelessness that characterizes our system today.

Meanwhile, several more states also legalized marijuana for either medical or recreational use. Marijuana has often been called a gateway drug. For many people with serious mental illnesses, it is a gateway to jail.

As state policies become friendlier to people who self-medicate, they could mitigate tougher federal sanctions.

This is why we must be vigilant. It will take some time for everything to sort itself out.