As the Senate heads toward a vote on its alternative to Obamacare—the Better Care Reconciliation Act—it’s essential to ask what the bill would mean for the millions of Americans with mental health conditions.

The word disastrous rises to the top of the list.

Because of a gradual, massive defunding of Medicaid and the allowance for states to opt out of mental health and substance abuse coverage, setbacks for individuals with mental illnesses would be huge, according to recent accounts from experts and professional organizations.

Medicaid is the public insurance that funds health care for children and individuals with disabilities, as well as certain older citizens. Funded in part by the federal government and in part by state contributions, Medicaid is the ultimate safety net for health care costs for individuals with low incomes—particularly children and families experiencing mental health and substance abuse conditions.

Over a 10-year period, the federal portions of Medicaid funding would be rolled back in a major way. And states could waive requirements that insurers cover Essential Health Benefits, including key mental health and substance abuse conditions. As a result, costs for people needing coverage for mental illnesses or substance use problems are estimated to go up dramatically, leaving far too many without needed treatments.

The stakes are high. Mental disorders are not only quite common but also quite impairing. Mood and anxiety disorders, schizophrenia-spectrum conditions, and child-onset disorders like ADHD and autism spectrum disorders reduce academic performance and job productivity, frequently wreaking havoc on relationships and families. Severe forms of mental disorders lower life expectancy, on average, by one to two decades, linked to poor health habits, proneness to physical diseases, risky behaviors, and self-destruction. Defying common stereotypes, people grappling with mental illnesses are far more likely to be victimized by violence than to perpetrate it. At the same time, suicide rates are ascending, particularly for young people.

The current opioid epidemic has led to tragic and increasingly publicized increases in death throughout the nation. Overall, substance use disorders tear families apart and produce major economic losses for communities, states, and the country at large.

For most of human history, mental-health conditions were believed to result from evil spirits or weak personal will. Ineffective parenting was blamed for much of the 20th century; more recently, "bad" genes have become the culprit. In truth, like heart disease, cancer, and diabetes, mental illnesses are usually shaped by genetic vulnerability but amplified by trauma or life stress. Although cures do not yet exist, evidence-based treatments can greatly facilitate recovery. Indeed, the average effects of mental health treatments are larger than those for most physical illnesses. Yet a 10-year gap, on average, exists between noticing core symptoms and pursuing intervention—because of ignorance, shame, or poor access to care. Such access would plunge under the new plan.

The backdrop is that even though the American public knows far more about mental health conditions than a generation or two ago, attitudes regarding mental illness have stayed flat or even worsened. Three times more U.S. citizens believe that mental illness is inevitably associated with violence than during the 1950s.

I learned the hard way. Growing up in a warm, academic, Midwestern family, I was baffled by my father’s periodic disappearances for months, even a year at a time. Nothing was said; the silence reigned supreme. Unspoken was that he was placed in barbaric mental hospitals (formerly called insane asylums) for bouts of wild moods and irrationality, misdiagnosed as schizophrenia. His doctors had told him and my mother, explicitly, that if my sister and I ever learned the reason for his disappearances, we would be permanently destroyed. Like most kids in situations of silence, I internalized the blame, wondering what I’d done wrong.

Only when I returned home for my first spring break from college did Dad start to discuss his life, full of achievement as a philosopher yet full of chaos given his bouts of what I soon correctly diagnosed as bipolar disorder. While fighting the terror that I would end up in the kinds of snake pits he had inhabited for much of his life, I became engaged in child and adolescent mental health, with the goal of reducing the stigma enshrouding the entire topic.

We must continue to fight for parity regarding mental health care and enforce antidiscrimination laws and practices, such as the Americans with Disabilities Act. Investing in evidence-based mental health treatments will yield major long-term savings, given the huge costs of untreated mental health conditions.

Mental illness has become the last frontier for human rights. We must take a stand, demanding parity of coverage for evidence-based assessment and treatment. We all lose by remaining silent and allowing access to dwindle.

About the Author

Stephen Hinshaw, Ph.D.

Stephen Hinshaw, Ph.D., is a professor and chair of the department of psychology at UC Berkeley. 

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Dimensions of Behavior