COVID-19, Mental Health, and the 2020 Election: A Review of Candidate Platforms

Amid the COVID-19 pandemic, many Americans are struggling with mental health challenges. In a recent KFF poll, majority (53%) of adults in the United States reported that their mental health has been negatively impacted due to worry and stress over the virus. Additionally, more than one in three adults in the U.S. reported symptoms of anxiety or depressive disorder during the pandemic, up from roughly one in ten in 2019. As the virus continues to spread, the pandemic will likely lead to increased mental health care needs and significantly impact the well-being of people in the U.S. Under the Trump administration, the recently-passed Coronavirus Aid, Relief, and Economic Security Act (CARES Act) may address some of these needs.

Mental health was already a key public health issue. In recent years, growing numbers of Americans have reported being depressed, and deaths due to drug or alcohol abuse, or suicide have increased. In 2017-2018, nearly 17 million adults and an additional 3 million adolescents had a major depressive episode in the past year, and over 10 million adults with mental illness had serious thoughts of suicide in the past year. Nearly 14 million adults reported an unmet need for mental health or substance use treatment, with many citing cost as a barrier.

The 2020 presidential election could have a substantial effect on the United States’ response to growing mental health needs and long-term policy for addressing this public health challenge. This issue brief examines the presumptive 2020 presidential candidates’ positions on mental health and substance use disorders. Specifically, we analyzed candidate positions on suicide prevention, mental health workforce issues, mental health parity enforcement, and the opioid epidemic. We synthesize policy positions for President Donald Trump and the presumed Democratic nominee, Former Vice President Joe Biden.

We identified candidate positions first by gathering information directly from campaign platforms as stated on candidate websites. Where information was not available on former Vice President Biden’s website, we supplemented with information his campaign supplied in a survey conducted by Mental Health for US, a nonpartisan coalition of organizations working in mental health and addiction policy. President Trump did not participate in the survey as of this brief’s publication, so we also reviewed news coverage of his campaign from the last year and his proposed 2021 budget for mention of these mental health-related topics. While candidates may have made other statements about mental health and substance use disorders, we do not aim to capture all comments ever made but instead focus on the candidates’ stated platforms.

The candidate platforms differ in both the amount of attention paid to mental health and their approaches to addressing these issues. Election outcomes thus have potentially large implications for policy direction in these areas of mental health and substance use funding, service delivery, and access.

Rising Suicide Rates & Suicide Prevention

Due to necessary social distancing, many people are experiencing isolation, distress, and barriers to accessing mental health services. Historically, national crisis hotlines have seen a spike in calls during distressing nationals events, and as the pandemic continues, calls to hotlines are on the rise. There is particular concern about suicidal ideation during this time, as isolation is a risk factor for suicide. In 2018, over 48,000 Americans died by suicide¹, and in 2017-2018, over ten million American adults (4.3%) reported having serious thoughts of suicide in the past year. Suicide is one of the top ten causes of death in the U.S. and accounts for majority of firearm deaths. Moreover, the Centers for Disease Control and Prevention (CDC) documents a substantial increase in the national suicide rate over time, with the age-adjusted suicide rate rising from 10.7 per 100,000 people in 2001 to 14.2 per 100,000 people in 2018 (Figure 1). Among working-age Americans (ages 16-64 years), the suicide rate rose by 40% over the same period. Both presidential candidates have offered suicide prevention plans with particular attention paid towards veterans, one subgroup at higher risk of suicide than the general population.

Figure 1: Suicide Rates in the United States, 2001 – 2018

President Trump’s suicide prevention plan focuses on the veteran population. His campaign website spotlights his 2019 executive order creating a task force dedicated to preventing suicides among veterans, and his proposed 2021 budget for the Department of Veterans Affairs allocates roughly 30% more in funding for suicide prevention among veterans than the 2020 enacted budget. Separately, in President Trump’s proposed 2021 budget for SAMHSA, he includes a small increase in funding for specific grant-based suicide prevention programs.

Former Vice President Biden’s suicide prevention plan is primarily focused on the veteran population. His campaign website details several initiatives that he would implement within the Veterans Affairs health system, which would increase funding for mental health services, streamline the initiation of mental health treatment, and increase the number of mental health staff practicing in VA hospitals. Former Vice President Biden’s plan states that he would also establish a national center of excellence for reducing veteran suicide to develop and implement suicide prevention strategies outside of the VA health system, and that he would address risk factors for suicide such as PTSD and sexual assault among current and former service members, though details on possible approaches are not provided. Additionally, in the context of the youth LGBTQ community, former Vice President Biden states that he will strengthen suicide prevention programs for teens, but does not provide specific details.

Mental Health Workforce Shortages

The need for mental health care is expected to increase in light of the coronavirus pandemic. Due to ongoing, widespread efforts to slow the spread of the virus by means of social distancing, an increasing number of mental health providers are offering services through telehealth, but those with limited capacity to do so may be scaling back their practices. Meanwhile, many individuals seeking mental health care are already unable to access care in a timely manner due to provider shortages across the country. Nationwide, nearly 117 million people are in a mental health provider shortage area, and less than 30% of the need for psychiatrists is being met.² Furthermore, HRSA projects there will be a nationwide shortfall of over 12,500 adult psychiatrists and over 11,500 addiction counselors by the year 2030. Access to pediatric providers is particularly problematic, with 70% of counties in the U.S. having no practicing child psychiatrist. Neither candidate has provided specific details on how they will increase the mental health workforce to address the lack of providers.

President Trump’s campaign website does not specifically address mental health workforce shortages. However, his 2021 budget proposal for HRSA indicates roughly a 24% increase in funding for behavioral health workforce development programs from 2019 to 2020, which would not change for 2021.

Former Vice President Biden’s campaign website does not specifically address mental health workforce shortages. However, in the context of his education plan, he states he will double the number of psychologists, guidance counselors, and other mental health professionals in schools. In a survey by Mental Health for US, former Vice President Biden states that he will increase funding for the National Health Service Corps and create partnerships between health centers, high schools, and community colleges in order to encourage youth to pursue health care jobs. He also adds that he will build on legislation such as the 21^st Century Cures Act and the Opioid Workforce Act of 2019, which address the shortage of mental health and substance use disorder providers.

Mental Health Parity

There is a focus on addressing access barriers for services many people need in relation to the coronavirus pandemic, such as potentially high cost-sharing for testing and treatment. Access to mental health and substance use disorder services is also a key need to address, and has its own challenges due to lingering issues with mental health parity. The Mental Health Parity and Addiction Equity Act (MHPAEA) was passed in 2008, requiring insurer coverage of mental health and substance use disorder services in a way that is equivalent to coverage for medical and surgical services. The law prohibits most group health plans that offer coverage for mental health and substance use conditions from imposing treatment limitations and financial requirements on those benefits that are stricter than for medical and surgical benefits. The 2010 Affordable Care Act (ACA) expanded MHPAEA’s reach by requiring coverage of behavioral health services as an “essential health benefit” in many private health plans (a notable exception being large employer plans) and extending parity requirements to the small group, individual, and Medicaid managed care markets. Since the MHPAEA took effect, changes in the use of mental health services have been modest. Additionally, while research has documented an effect of parity on equalizing quantitative treatment limitations and cost sharing, it has been more difficult to measure and regulate the law’s effect on non-quantifiable treatment limitations, such as prior authorization and network adequacy, which are also supposed to be provided at parity. Questions remain as to how to improve parity enforcement; so far, both candidates have offered limited details.

President Trump’s campaign website does not address parity for mental health services. The Trump administration has joined Texas and several other states in Texas v. U.S. (known as California v. Texas by the Supreme Court, which recently agreed to hear the case), arguing that the ACA should be invalidated, an outcome that would substantially limit the scope of parity rules and eliminate the essential health benefit requirement. The Trump administration has also expanded the allowed duration of short-term health plans, which do not have to comply with ACA requirements, typically do not cover mental health services, and generally exclude people with pre-existing conditions such as serious mental illnesses.

Former Vice President Biden’s campaign website says that, as president, he would “redouble” efforts to enforce existing mental health parity laws and expand funding for mental health. He points to his previous role in implementing the MHPAEA but does not specify which actions his administration would take to further enforcement.

The Opioid Epidemic and Drug Overdoses

Preliminary data shows that deaths due to drug overdose are increasing during the coronavirus pandemic. This may be a result of necessary lockdowns, barriers to care, and the economic recession.  Prior to the pandemic, deaths due to opioid overdose saw large increases, from 2.9 deaths per 100,000 people in 1999 to 14.6 deaths per 100,000 people in 2018 (Figure 2). In response to the growing opioid epidemic, the Department of Health and Human Services declared a public health emergency in 2017 and introduced five strategies: 1) improving access to treatment, 2) increasing use of drugs to reverse overdoses, 3) public health surveillance, 4) research on pain and addiction, and 5) identifying better practices to manage pain. In recent years, several indicators have shown some improvement in opioid misuse or overdose, but rising rates of use or misuse of illicit drugs—including methamphetamine, cocaine, and benzodiazepines—have broadened the scope of the addiction crisis. Each presidential candidate has proposed strategies to address the opioid epidemic and substance use disorder going forward, including details on making medication-assisted treatment³ more widely available.

Figure 2: Opioid Overdose Death Rate in the United States, 1999-2018

President Trump’s reelection campaign website states that addressing the opioid epidemic has been a priority for his administration, which declared the crisis a national public health emergency in late 2017 and has since renewed the declaration every 90 days. He also signed legislation approving additional grant funds to combat the opioid epidemic, including the SUPPORT for Patients and Community Act. However, President Trump’s proposed 2021 budget would continue to decrease total funding for both the Substance Abuse and Mental Health Services Administration (SAMHSA) and Medicaid – the U.S.’s largest payer for mental health services and a main contributor for substance use disorder services. Despite these overall cuts, the proposed budget for SAMHSA includes a small increase in state grants to address opioid use disorders, and the proposed budget for Medicaid includes increased funding over ten years for states to extend postpartum coverage for women with substance use disorders. The proposed budget for opioid response programs in rural areas under the Health Resources and Services Administration (HRSA) remains flat for 2020 and 2021, but down from 2019.

Former Vice President Biden’s campaign website outlines a detailed, five-point plan to address the opioid crisis. First, it states how he will monitor and hold pharmaceutical companies accountable for their role in the crisis, notably by banning pharmaceutical companies from financially incentivizing prescriptions and appointing an “Opioid Crisis Accountability Coordinator” to work with both federal and state-level efforts. Second, former Vice President Biden states that he will increase access to substance use disorder services through a $125 billion investment over a ten-year period. These investments will include making medication-assisted treatment universally accessible by 2025 by building on the 21^st Century Cures Act; providing funding to underserved communities with high rates of substance use disorder; and increasing funding for the National Institutes of Health’s Helping to End Addiction Long-Term research initiative. His third point indicates several ways he intends to stop the unnecessary prescription of opioids, including having states require prescriber participation in prescription drug monitoring programs and supporting the use of alternative pain treatments and development of less addictive pain medications. The final two points of former Vice President Biden’s statement focus on reducing the amount of illicit drugs entering the U.S. and diverting incarceration based solely on drug use to drug courts and treatment services.

Discussion

As the novel coronavirus pandemic continues, it spotlights the importance of mental health issues in the lead-up to the 2020 election. The pandemic is expected to not only exacerbate the existing mental health issues and barriers to care that people face, but to also increase the need for already limited mental health services. President Trump and former Vice President Biden have taken stances on several mental health issues, including the opioid crisis, rising suicide rates, and – to a more limited extent –  parity in coverage for mental health services and nationwide shortages in the mental health workforce.

• Suicide Prevention: Both of the presumptive 2020 presidential candidates give special attention to veterans in their suicide prevention plans and plan to expand access to mental health services through the VA health system.
• Mental Health Workforce: Former Vice President Biden supports increasing the mental health workforce, including expansion of national service organizations such as the National Health Service Corps.
• Mental Health Parity: The candidates do not provide specific plans to enforce the mental health parity requirements of the MHPAEA and ACA, and President Trump, more broadly, is arguing in court that the ACA should be invalidated.
• Opioids: Both President Trump and former Vice President Biden have presented plans to expand access to treatment services such as medication-assisted treatment programs. In addition to this, former Vice President Biden emphasizes holding pharmaceutical companies and drug manufacturers accountable and intends to stop the overprescribing of opioids.

Beyond the candidates’ specific plans, a number of major election issues have implications for mental health, including immigration, gun violence, and the future of the ACA.

The subjects of immigration and border security remain prominent in President Trump’s reelection campaign. Several mental health experts have weighed in on the Trump administration’s policy of separating families at the U.S.’s southern border, raising concerns that children separated from their parents and detained at border facilities may be at substantially elevated risk of developing mental health conditions. Former Vice President Biden has stated he would end current practices of long-term detention, separating families, and workplace immigration raids.

President Trump has responded to recent mass shootings by arguing that gun violence is best addressed as a mental health issue. The Trump administration has considered researching whether technological devices can be used to monitor people with mental illnesses in order to prevent them from committing violent acts. However, most scientific evidence does not support a direct link between mental illness and gun violence, and instead suggests that people with mental illness are more likely to be victims of violence than perpetrators. Former Vice President Biden supports stronger gun control, including universal background checks and an assault weapons ban.

The future of the ACA remains uncertain, as the Trump administration has joined Texas and several other states in pushing to invalidate the law in Texas v. U.S. Because the ACA’s provisions require insurers to cover mental health care and substance abuse treatment, a ruling against the law would likely reduce access to these services for many Americans. Particularly if the ACA is struck down, these actions may limit the federal administration’s capacity to reduce opioid overdose deaths and suicide rates, and would undermine efforts to achieve parity for mental health coverage. Former Vice President Biden has criticized efforts to have the ACA invalidated. In an open letter written to President Trump on the tenth anniversary of the ACA, the former vice president highlighted the ACA’s role as a safety net during the coronavirus pandemic and the potential impacts of dismantling it. Former Vice President Biden’s proposed health care plan includes public option programs that would preserve ACA marketplaces and increase subsidies for marketplace plans.