The Issue

About one-quarter of U.S. adults report having a mental health diagnosis such as anxiety or depression, or say they are experiencing emotional distress. People with mental health conditions are at significantly higher risk for other health problems and complications, including chronic conditions like diabetes and heart disease, and substance use. Adults with mental health disorders and chronic conditions account for three times more health care spending than adults with chronic conditions only.

Americans have some of the worst mental health–related outcomes, including the highest suicide rate and second-highest drug-related death rate among high-income countries. The COVID-19 pandemic is intensifying the demand for services and treatment; an additional 75,0000 people are projected to die from suicide and alcohol or drug misuse before the economy fully recovers.

Medicaid is the largest payer of mental health and substance use treatment in the United States. Through coverage expansions and other provisions, the Affordable Care Act (ACA) made significant changes in Americans’ ability to access and afford mental health treatment and services.

The Candidates’ Approaches

President Donald Trump

Mental Health

  • The Trump administration seeks to repeal the ACA. This will undo coverage and payment protections that expanded Medicaid; extended mental health parity requirements to the small-group, individual, and Medicaid managed care markets; and required coverage of mental health services as an “essential health benefit” in many private health plans. Repealing the ACA will limit patients’ access to mental health services.
  • In response to a documented shortage of mental health providers, the Trump administration’s 2021 budget proposed a 24 percent increase in behavioral health workforce development programs through the Health Resources and Services Administration.
  • The Trump administration has expressed intent in addressing suicide among veterans. It created the President’s Roadmap to Empower Veterans and End a National Tragedy of Suicide (PREVENTS) Task Force to focus on suicide prevention among veterans and proposed a funding increase for the Department of Veterans Affairs in 2021.
  • In response to the COVID-19 pandemic, President Trump released an executive order setting pandemic-related mental health needs as a priority, with the goal of preventing suicide, drug-related deaths, and poor behavioral health outcomes.

Substance Use

In response to the opioid epidemic, President Trump declared a national public health emergency in 2017 and has provided several billion dollars in grants to states for treatment, prevention, and recovery services and for expanding access to buprenorphine treatment for addiction.

Vice President Joe Biden

Mental Health

Vice President Biden has committed to protecting and building on the ACA to ensure coverage expansion and protections for mental health services. He has pledged to “redouble efforts” to enforce existing mental health parity laws and expand funding for mental health.

To ensure access to mental health providers, Biden has called for investing in training and hiring more mental health clinicians, substance use disorder counselors, and peer support counselors while also increasing training for health care professionals, educators, and social workers.

In recognizing the unique mental health needs of different communities, Biden has proposed:

  • doubling the number of psychologists, counselors, and other mental health professionals in schools
  • expanding and strengthening veterans’ mental health programs both within and outside the Veterans Health Administration
  • strengthening programs aimed at reducing suicide among LGBTQ teenagers
  • expanding access to care for mental health and substance use disorders during and after incarceration.

Substance Use

Vice President Biden released a plan to address the opioid crisis that would increase access to services, curb unnecessary opioid prescriptions, and hold pharmaceutical companies accountable for their role in the crisis. He has proposed to make medication-assisted treatment (MAT) available to all who need it.

Vice President Biden has voiced support for exploring incarceration alternatives for those with mental health disorders. Potential solutions include increased use of drug courts, harm reduction interventions, and treatment diversion programs.

Implications of the Candidates’ Approaches

To assess the implications of the candidates’ approaches to mental health and substance use disorders, the public might consider the following questions:

I have a mental health diagnosis and recently lost my job. Will I be able to find a plan that covers my mental health treatment needs?

A mental health diagnosis such as depression is considered a preexisting condition. Under the ACA, marketplace plans cannot refuse you coverage, charge you more for coverage, or subject you to a waiting period because of your condition. Vice President Biden has pledged to build on the law’s coverage and protections, while President Trump advocates the repeal of the ACA.

If the ACA is struck down by the Supreme Court, preexisting condition protections would be struck down as well. While the President has announced his intention to ensure preexisting conditions remain covered, Congress would need to take legislative action to ensure these protections in the absence of the Affordable Care Act.

How would the candidates address the ongoing opioid epidemic and ensure adequate prevention and treatment for the hardest-hit communities?

In April 2017, the Trump administration announced that its strategy to combat the crisis would include better addiction prevention, treatment, and recovery services; enhanced data; improvements in pain management; advanced targeting of overdose-reversing drugs; and more research. The administration has allocated nearly $2 billion in grants to states for prevention and treatment strategies, as well as for enhancing data capabilities to track and monitor drug-related deaths.

Vice President Biden has pledged to make effective prevention, treatment, and recovery services available to all. He has proposed a $125 billion federal investment to do so, part of which would be targeted support for states and localities. Biden also favors better integrated primary care and behavioral health, in addition to pursuing cost-effective, evidence-based prevention strategies.