The United States is in the midst of its rite of choosing its next President. As a blog focused on mental health and psychology, we can’t help but wonder about the candidates’ commitment to mental health and psychological science. We should note that we hold no specific political agenda and endorse neither candidate at this time. Because this article is so long, we’ve provided an easy-to-read summary of our findings at they very end.
One way to determine a candidate’s position on such issues is to send out a questionnaire about mental health policy issues and ask the candidates to fill it out. This is what NAMI does (and did a year ago for the two current candidates), and you can view the responses here.
Not unexpectedly, Obama’s campaign responded by “Strongly supporting” every question asked about a mental health issue. You can’t go wrong filling it out that way, regardless of your intentions, because it means easy votes that nobody will ever hold you to if you become President. (His campaign also provided this statement when queried further about his stance on mental illness issues.)
McCain’s campaign either saw how ridiculous and transparent the survey was, or didn’t want to be painted into any corners early on, and declined to answer the questionnaire. But he did provide a statement about mental health care, a part of which I’ll quote:
Mental health is a necessary complement to physical health in all aspects of our daily lives. Fortunately, the path to greater quality and lower costs is to recognize this fact and where possible provide incentives to treat physical and behavioral health together. Chronic disease is a dominant component of the growth in spending on health care and many of our citizens with chronic illnesses have a behavioral health problem as well. For example, untreated depression raises dramatically the cost of treating the physical ailments of a diabetic. A sensible goal is to design reimbursement for taking care of the whole patient, whatever ails them, and recognize the essential role mental health treatment plays in the overall health of the patient and the reduction in physical health needs.
I have stressed the central role of personal responsibility in leading to lower health care costs. Personal fitness and better lifestyles, especially reduction in addictions of all types – food, narcotics, or cigarettes – can yield dramatic improvements in the cost of chronic illness and high‐cost medical care. We can do a better job of treating addictions, but we also have an obligation to do a better job of teaching our children the benefits of good lifestyles and the perils of addictive activities.
Good stuff, and without saying it, apparently agrees with mental health parity but stresses personal responsibility, especially in regards to addictions (suggesting maybe he wouldn’t take them as seriously as other mental health concerns).
I don’t think the questionnaire route is a very good one to determine the candidates’ stances on these issues, because politicians are used to promising everything and then delivering little (with plenty of excuses and rationalizations for not making good on their promises).
No, the better and more reliable way of looking at a candidate’s stance is simply to look at what they’ve voted for and supported in the past, and how their home states do in the area of mental health care. After all, as representatives in the Senate of their respective states, they are partially responsible for how their states approach mental healthcare.
Voting Records of McCain and Obama
We looked at the voting records of McCain and Obama in their capacity as Senators for their respective home states over the past few years to gauge their typical voting patterns on a number of issues directly relevant to mental health and psychology.
Mental health providers need to be adequately reimbursed for providing their services, or else they get out of the business. Medicare is a huge source of funding for mental health providers. So passage of the 2008 Medicare bill, which extended important expiring provisions under the program that improves beneficiary access to preventive and mental health services, enhances low-income benefit programs, and maintains access to care in rural areas, including pharmacy access, is a key indicator of support. The Senate passed the bill with a veto-proof override on July 15, 2008, 70 to 26. McCain did not vote on the bill, nor did Obama. They were too busy campaigning to bother to cast their votes. Cloture was needed, however, to get this bill to a vote. Obama did vote yes on the cloture vote, while McCain did not vote on cloture.
Earlier in the year, an important amendment reached the Senate that would halt the cut of certain Medicaid programs that were designed to help low-income families get themselves out of poverty, including case management services and rehabilitation services. These services were targeted at people with mental illness to help them manage their medications and live a healthy life within their communities instead of being imprisoned or hospitalized. McCain, busy again on the campaign trail, did not vote. Obama voted Yes.
The Congressional Budget for 2008, which passed 52 to 47, included increases in the budgets of the National Institutes of Health (2.1%) and the National Science Foundation (2.5%). McCain voted No on this resolution and Obama voted Yes.
The Congressional Budget for 2007, which passed 51 to 49, included increases in the budgets of the National Institutes of Health (3.5%), the National Science Foundation (6.3%), and Pell grants (the first increase in 4 years). It also included an over 10% increase for funding of veterans’ healthcare needs. Obama voted No on this bill, McCain — a veteran — voted Yes.
The Congressional Budget for 2006, which passed 51 to 49, included increases in the budgets of the National Institutes of Health (3.6%) and the National Science Foundation (2.4%). Obama voted No on this bill and McCain voted Yes.
It’s hard to draw any conclusions from this pattern of votes, since Senators may vote yea or nay on a resolution for political or ideological reasons which are not noted in the public record (or require a great deal more research to determine). Congressional Budgets are non-binding, mean they don’t have the force of law anyway, but serve as a blueprint for that year’s spending by various Senate appropriations committees.
Mental Health Parity
Mental health parity was the big issue in late 2007, as the Senate passed s. 558 (and the House passed HR 1424) to require that mental illness diagnoses get equal reimbursement (“parity”) as regular physical illness diagnoses. Traditionally, this has not been the case for most insurance companies, who place limits on the extent and type of treatment one can receive for things like depression or bipolar disorder.
Fifty-seven Senators, including Obama (but not McCain) were co-sponsors of the Senate version of the bill. The Senate unanimously passed the bill on September 18, 2007. It passed the House on March 5, 2008. It has languished since then in the committee to work out the differences between the two bills. The policy and language of the House-Senate compromise has been agreed to in s. 3335, but key committees are still seeking provisions to offset the cost of the bill. They must agree on the source of $3.8 billion in offsets required under the Budget Act.
This report describes the key compromises:
Definition of mental health benefits subject to parity requirement: mental health and substance abuse disorder benefits are defined under the terms of the plan and in accordance with applicable federal and state law. State law may continue to define what benefits a fully insured plan may be required to cover, but not a self-insured plan. The requirement to use the requirement to use the Diagnostic and Statistical Manual of Mental Disorders (DSM IV) (the compendium of mental health conditions) to determine what benefits must be covered is not included in the measure.
Protection of plan medical management practices: no provision prohibits plan medical management practices or mandates parity in medical management. The agreement includes a rule of construction that it does not affect “terms and conditions” of plans to the extent that they do not conflict with the parity requirements. This language should protect medical necessity provisions. The agreement requires plans to make available their criteria for medical necessity determinations and the reason for any denial of any reimbursement or payment for services for mental health or substance abuse benefits.
Out-of-network coverage: a plan must provide out-of-network coverage for mental health and substance abuse disorders in a manner consistent with the parity requirement if out-of-network coverage is provided for medical and surgical benefits. Other applicable plan terms and conditions, such as those related to medical management, would continue to apply.
Relationship to state laws and remedies: The agreement applies the current law “HIPAA standard” which establishes the federal requirements as a floor and permits states to enact more extensive requirements for insured plans, provided that such laws do not conflict with federal law. The agreement also applies the current law ERISA remedy framework to new mental health parity requirements.
In other words, we get mental health parity (if the bill passes the House and Senate again and the President signs it), but it’s a bit watered down. Also included in the final bill is the 1%/2% exemption clause we noted that appeared in the original versions of both bills. This exempts any health care plan from having to provide mental health parity coverage if it will increase their costs more than 2% in the first year, or more than 1% any year after that. I don’t think it’s going to be hard to show that providing parity coverage is going to increase their overall healthcare costs more than 1%, especially if more people actually start using the benefit. And of course, small employers (under 50 employees) are also exempt.
The Melanie Blocker Stokes Mothers Act
The Melanie Blocker Stokes Mothers Act is a somewhat controversial piece of legislation introduced in 2007 and co-sponsored by 10 Senators, including Senator Hillary Clinton and Senator Barack Obama. If you read the actual wording of the bill, it does not mandate mental health screenings for all new mothers. Instead, it instructs healthcare professionals to offer such screenings — new mothers who do not want the screening can simply refuse. You can read more about the Mothers Act here and responses to the great deal of misinformation and lies being spread about this proposed law.
I’m a big advocate of mental health screenings. We’ve had millions of people take our mental health screenings on Psych Central, which help people understand whether they may have a concern that needs further treatment. While ignorance of mental health issues might be fine for some people, we believe the more light we shed on serious issues like post-partum depression, the better. And mental health screenings of new mothers seem like a reasonable step.
The bill is in a Senate committee right now, so there are no votes to tally on it. But it’s telling that Obama signed on as a co-sponsor of the bill — an action showing strong support for such screenings.
Their State’s Report Card
NAMI’s latest Grading the States report was in 2006 and neither candidate’s states fared very well. McCain’s home state of Arizona received a grade of “D” and Obama’s home state of Illinois received an “F.”
|Arizona (McCain)||Illinois (Obama)|
|Per Capita Mental Health Spending:||$126.33||$66.12|
|Per Capita Income:||$25,481||$31,987|
|Total Mental Health Spending (in millions):||$702||$835|
|Suicide Rank (out of 50):||6||44|
I will point out some obvious differences between the two states and candidates. McCain has been in Congress since 1982, some 26 years, representing his state’s interests. Obama, in contrast, has only been in Congress since 2005, and has had far less time to divert money or resources to his state to help with mental health concerns. Illinois is also home to Chicago, a far larger city than Arizona’s largest city, Phoenix. Large, older cities like Chicago tend to have larger, more intractable social systems in place that make it difficult to effect significant change. However, Illinois is spending only about half of what Arizona is spending on mental health care.
Neither state has done well on this “report card,” but I would also note that the report card itself is badly skewed to the negative end of the spectrum, with no state receiving an “A” grade and only a handful garnering a “B.” This report card reflects no Bell curve, but rather a skewed curve to forward NAMI’s own policy agenda of effecting significant change within states. One could argue that it’s perhaps more of a public relations tool than a serious piece of research.
We didn’t compare the Vice Presidential candidates’ stances on mental healthcare because, frankly, there’s no comparison. Senator Joe Biden has been a long-standing advocate in the Senate for people with health and mental health issues, including protection and full funding for Medicare and Medicaid programs. He also is on record for supporting full mental health parity and was co-sponsor of the bills brought before the Senate on this issue. His opponent, Gov. Sarah Palin, has no national record on mental health issues; Alaska received a “D” grade on NAMI’s report card (although Palin took office after this report card was released). Last week, Alaska and Gov. Palin were sued by the Law Project for Psychiatric Rights to address the “excessive, ineffective, and extremely harmful psychiatric drugging of Alaskan children and youth.” And her newsworthy mental health efforts in Alaska? Pushing for more aggressive development of the lands that Alaska’s Mental Health Trust owns.
Based upon our findings, we’d have to say the stronger mental health and psychology candidate is Obama. Whereas McCain tends to support mental health causes when in the majority, he doesn’t appear to go out on a limb for anything in the areas of mental health or psychological sciences funding. Obama, on the other hand, has co-sponsored a major piece of Senate legislation in mental health (mental health parity) and shows he understands the stigma still associated with mental health issues in his co-sponsorship of the Mothers Act.
The differences between these two candidates’s stances on mental health issues are not clearly significant. They both appear to appreciate that mental health often gets the short end of the stick when it comes to healthcare policy decisions in general, and we believe would both work to help end the discrimination that exists today for people with a mental illness.
|NAMI Questionnaire||Provided Statement||Answered “Strongly Supports” to all questions|
|Medicare/Medicaid Votes||NV, NV, NV||NV, Yes, Yes|
|Federal Budgets||No, Yes, Yes||Yes, No, No|
|Mental Health Parity||Yes||Yes (Co-sponsor)|
|Mental Health Screenings||Unknown||Yes (Co-sponsor)|
|State’s Mental Health Rankings||D (per capita spending: $126)||F (per capita spending: $66)|
|Psych Central’s Ranking||2||1|
|NV = Did not vote|
We think it is short-sighted and fairly ridiculous to vote on a presidential candidate on the basis of a single issue. So we will not be making presidential voting decisions based solely on the information found here.
But it can help one make a better informed decision about the candidate as a whole and help us understand whether they truly comprehend the complexity that people suffering from a mental disorder face in today’s society. We believe that both candidates do, but that Obama is a more vocal and forceful advocate for people who grapple with mental health concerns.
For More Information…
2008 Presidential Candidate Health Care Proposals: Side by Side Summary – Kaiser Family Foundation