Dr. Nathan Greene is a clinical psychologist who works with adults and children in California. In this Opinion Piece, Dr. Greene discusses his concerns about the future of mental healthcare in light of the upcoming 2020 election in the United States. He shares his worries over the future of the Affordable Care Act and urges us to ‘act now and send a clear message at the ballot box.’

‘The stakes couldn’t be higher for the future of mental health’

I sit alone in my downtown Oakland, CA, psychotherapy office in front of my laptop, a sterile two-dimensional portal to my clients, and the only tool I now have to facilitate the intimate space of psychotherapy.

I scan my inbox full of requests from suffering adults and children who I won’t be able to treat and am overcome with dread as I think about the unending need for support. I am often the fifth or sixth clinician they have called, only to find that our caseloads are full or that their insurance providers do not cover our services.

My fear is not just for these people but also for everyone in the U.S. suffering right now on their own.

On a deeper level, I fear for the future of this dysfunctional mental health system that I am a part of, a system that has proven to be woefully unequipped to handle the worst mental health crisis our nation has ever seen.

When I turn to the news for my obligatory check-in (which I try to limit to once a day, as I advise my clients who are managing anxiety), I only find further indications of how dire the situation is.

I see our current president continue to callously dismantle the very healthcare system we rely upon without offering up a viable alternative for when the rug is inevitably pulled out from under us.

As we head to the polls (or our mailboxes) to decide our nation’s course, the stakes couldn’t be higher for the future of mental health.

How did we get here? (A tale of three pandemics)

We arrived at this inflection point through a confluence of pandemics and policy. One pandemic has taken center stage in the national conversation.

But in reality, we are in the midst of three: the COVID-19 crisis, a nation’s reckoning with generations of racial violence and inequity, and the fallout from our rapidly changing climate.

The mental health impact of these three pandemics has been staggering.

This year, we’ve seen historic rises in depression, anxiety, and suicidality across all sectors of the population. According to a report from the Kaiser Family Foundation in July 2020, more than 1 in 3 adults are experiencing symptoms of anxiety or depressive disorder, roughly three times the number of people who reported the same problems last year.

People in the United States are finding it more difficult to eat healthfully and sleep appropriately. They are also consuming more alcohol than they have before.

I see these impacts in my Oakland-based psychotherapy practice, specifically, where people from ages 8 to 50 are returning for treatment after having successfully overcome mental health episodes years before.

Children who had slept alone for years have returned to their parents’ beds due to nightmares. Among adults, intimate partner violence is on the rise.

‘Death by a thousand cuts’

Unsurprisingly, the psychological impacts of these crises have weighed most heavily on our most vulnerable populations: BIPOC (black, indigenous, and people of color), those living in poverty, and the elderly.

These groups are experiencing greater numbers of COVID-19 illness and death. Their mental health is also clearly suffering due to COVID-related stress.

These negative impacts on mental health are compounded for the BIPOC community due to rising racial stress and discrimination in this country.

We have indisputable evidence that experiences of racism and prejudice have a significant detrimental effect on mental and even physical health. Such experiences have links to depression, anxiety, immune system changes, increases in hypertension, and even chronic inflammation.

Police officers aren’t the only cause of violence against people of color; day-to-day racist encounters have a cumulative effect on the body and contribute deeply to the health crisis. Prejudice leads to death by a thousand cuts.

Our country is also confronting unprecedented climate change-related disasters, compounding the devastation.

In 2017, the American Psychological Association released a report linking climate change and related disasters with short-term symptoms of post-traumatic stress disorder (PTSD) and anxiety and chronic and severe mental health conditions.

In my home state of California, much of our land has been either on fire or immersed in smoke over the past 3 months, moving climate change from being an abstract fear to a sobering reality.

The stress is palpable. One of my clients at my psychotherapy practice, a father of young children, is so concerned about his children’s future that he is considering uprooting his family, leaving his job, and moving across the country to a region where climate change-related disasters are less likely.

A Broken System

The mental healthcare system we have in place is woefully inadequate to handle these unprecedented crises.

Urgent repair is needed, and President Trump is hell-bent on running the country in the opposite direction by gutting his predecessor’s hallmark achievements.

He has reached many of his catastrophic goals.

While the ACA expanded access to mental healthcare to over 20 million Americans, these services remain chronically underfunded in private and public insurance spheres. The result is a country in which many individuals have to cope on their own.

The broken nature of our private mental healthcare system came into the public eye in California in 2018 and 2019 when more than 4,000 mental health practitioners engaged in multiday strikes against Kaiser Permanente, the largest health insurer in the state.

Therapists were striking against a company bringing in record profit while understaffing their mental health teams so severely that their therapists could see over 500 psychotherapy clients in a year. Some people with severe mental health diagnoses had to wait up to 6 to 8 weeks between sessions.

This amounts to malpractice on a massive scale. Just 5 years before, Kaiser had been forced by the court to pay a $4 million fine for providing inadequate access to mental health services.

Clearly, that hadn’t been enough motivation to make mental health access a priority.

The future of the ACA

Things are not looking better when it comes to our public programs. For 4 years, Trump has actively sabotaged the ACA through deliberate actions limiting access to the ACA insurance exchange, cutting the subsidies to participating insurers, and decreasing regulatory standards for coverage.

The Republicans’ successful whittling away of the ACA contributed to the rise of uninsured people in this country from an all-time low of 11% in 2016 to 14% in 2019. That equates to millions of people in the U.S. losing coverage.

Throughout his presidency, Trump has also launched an active assault on Medicaid, the single largest payer toward behavioral health sciences, which serves as the foundation of community-based mental health.

And most recently and egregiously, Trump has supported overturning the ACA in its entirety through a legal challenge that has found its way to the Supreme Court, with oral arguments set to be heard on November 10^th.

Supreme court nominee Amy Coney Barrett has publicly criticized the legality of the ACA and, if confirmed, could provide the vote necessary to overturn the bill.

Amid three pandemics, Trump has denied the existence of two and consistently downplayed and lied about the third.

How can we expect him to solve problems that he doesn’t even view as real? What’s worse, while these pandemics have been raging, he has actively been dismantling structures of support.

Where do we go from here?

When it comes to our options for the future of mental health, the choices at the ballot box are in stark contrast.

Stated simply, Joe Biden has devised specific plans for expanding and fortifying the ACA. Trump has positioned himself squarely against it without offering anything substantive in terms of an alternative system.

Biden’s platform and budget plan include ACA expansion, increased federal funding for mental health services, and enforcement of parity in mental health coverage.

He also has laid out a five-point plan with $125 billion in funding to address the opioid crisis (epidemic number 4, which has recently been overshadowed by the others). These changes will not fix the system in its entirety, but they are a good start.

Trump’s long-promised “America-First Healthcare Plan,” in contrast, is a barebones statement of hollow intentions for lower costs, more choices, and better plans.

It rehashes what Trump has done thus far without any real policy or funding roadmap for how he plans to achieve these goals. True to form, Trump is without a plan.

What Trump has promised is a budget for 2021 that calls for $1 trillion in cuts to Medicaid and the ACA.

And this past month, under Trump’s watch, The Centers for Medicare and Medicaid Services (CMS) has proposed a 10.6% reduction in payment rates for all providers in 2021, including physicians and psychologists.

If passed, this will spell continued decimation of mental health access, as it will discourage clinicians from paneling with Medicare, choosing instead to provide fee-for-service practices.

These policies together will continue to decimate our already broken system.

‘Act now and send a clear message’

However, there are some promising state-level developments here in California. In September, Governor Gavin Newsom signed into law a progressive mental health bill that will require all private insurers to cover medically necessary mental health and drug addiction treatments.

The bill also gives mental health experts a seat at the table in determining what qualifies as a medical necessity. This is important because it will prevent health insurers from creating arbitrary barriers to drug treatment and psychotherapy.

Situated in the eye of three pandemics, the state of California has served as a small beacon of hope. While Newsom has taken the first steps toward fixing our broken system, a comprehensive overhaul of our mental healthcare system is needed.

We must act now and send a clear message at the ballot box that we view access to mental healthcare as a human right.

If we do, then when an adult, adolescent, or child takes the courageous step of reaching out to a therapist like myself for help, there will actually be a system in place to support them regardless of their income or insurance provider.

I’d then be able to sit in my office, focusing on my clients’ needs instead of fretting about the many more who may never find the care they deserve and need.

If we fail to act at this crucial inflection point, the psychological trauma, substance abuse, and myriad of debilitating mental health conditions brought about by these three pandemics will harm generations to come.

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