2020 Presidential Candidate Survey on Disability: Mental Health Services

Joe Biden

Our culture and health care systems too often treat mental illness as different from physical health conditions. It’s wrong. As Vice President, I was a champion for efforts to implement the federal mental health parity law, improve access to mental health care, and eliminate the stigma around mental health. As president, I will redouble these efforts to reduce stigma, ensure enforcement of mental health parity laws, and expand funding for mental health services.

I am proud that the Affordable Care Act (ACA) provided individuals with pre-existing conditions, including a mental health challenge, access to health insurance. People with disabilities were a arge beneficiary of this new policy, including those with mental health conditions. The ACA also requires insurance companies to cover mental and behavioral health treatment as an essential benefit, and cover that care at parity with physical health benefits. And, the ACA gave 60 million Americans access to mental health and substance use disorder benefits.

Yet, despite this progress, I know that our parity laws are under-enforced and too many people are still denied the mental health care they need. As president, I will make sure enforcing our mental health parity laws is a priority. Currently states vary in how they define essential health benefits when it comes to mental health. In my Administration, we will set clear standards raising the bar for mental health coverage, including habilitative services and other forms of behavioral health care.

I will also build on the Affordable Care Act to make sure low-income individuals with mental health disabilities have access to insurance. Access to affordable health insurance that includes coverage for mental health shouldn’t depend on your zip code or income. Governors and state legislatures in 14 states have refused to take up the Affordable Care Act’s expansion of Medicaid eligibility, denying access to Medicaid for an estimated 4.5 million adults. My plan will ensure these individuals get covered by offering premium-free access to the public option for those 4.5 million individuals who would be eligible for Medicaid but for their state’s inaction, and making sure their public option covers the full scope of Medicaid benefits. States that have already expanded Medicaid will have the choice of moving the expansion population to the premium-free public option as long as the states continue to pay their current share of the cost of covering those individuals. Additionally, I will ensure people making below 138% of the federal poverty level get covered. I’ll do this by automatically enrolling these individuals when they interact with certain institutions (such as public schools) or other programs for
low-income populations (such as SNAP).

I will also ensure my Department of Health and Human Services stops states from privatizing Medicaid and allowing private companies to profit off Medicaid while cutting services for those who need them the most. I will also expand primary care and innovative health care delivery models in rural communities. One way I will do this is by building new health clinics and deploying telehealth in rural America.
The Obama-Biden Administration successfully used the USDA Community Facility Direct Loan & Grant Program to build rural hospitals and mental health clinics across rural America and equip them with the best technology. As president, I will expand this grant funding, with a focus on accelerating the deployment of telehealth for mental health and specialty care. Telehealth – the use of videoconferencing and other technology to provide remote care – can be a vital resource for rural communities with limited access to providers.

Too many people with mental health or substance use disorders end up incarcerated. I will expand federal funding for mental health and substance use disorder services and research. People with mental health disabilities or substance use disorders should have access to
affordable, quality care long before their situations escalate and they interact with the criminal justice system. As noted above, the Biden Plan will expand health insurance coverage so more Americans have access to treatment, ensure enforcement of mental health parity laws, and expand funding for mental health services.

I will also get people who should be supported with social services – instead of in our prisons – connected to the help they need. Too often, those in need of mental health care or rehabilitation for a substance use disorder do not get the necessary care. Instead, they end up
having interactions with law enforcement that lead to incarceration. The same is true for homeless individuals. That’s not fair to those individuals, and it’s not fair to police officers. To change the nature of these interactions, the Biden Administration will fund initiatives to partner mental health and substance use disorder experts, social workers, and disability advocates with police departments. These service providers will train police officers to better de-escalate interactions with people in severe emotional distress. They’ll also help police officers learn how to better approach individuals with certain disabilities, like those with autism or who are deaf, so misunderstanding does not lead to incarceration or worse. And, these service providers will respond to calls with police officers so individuals who should not be in the criminal justice system are diverted to treatment for addiction or a mental health disability, or are provided with the housing or other social services they may need.

I will also expand access to mental health and substance use disorder treatment, as well as educational opportunities and job training for individuals during and after incarceration. Jails are not the preferred approach for rehabilitation. That’s why the Biden Administration will
expand the use of drug courts and other diversion programs. But, when individuals end up incarcerated and are experiencing a mental health condition or a substance use disorder, they should have access to adequate treatment. And, all incarcerated individuals should have the opportunity to pursue education and skills training so they can more easily find employment after their release. Incarcerated individuals should have the opportunity to learn to read, earn a GED, or learn a new trade while imprisoned. The Biden Administration will expand funding for all of these programs and services, during and after incarceration.

Because I also want to make sure that our kids get the mental health care they need, I will double the number of psychologists, guidance counselors, nurses, social workers, and other health professionals in our schools. One in five children in the U.S. experience a mental health condition. Yet, too many of our children are not getting the mental health care they need from a trained professional. We need mental health professionals in our schools to help provide quality mental health care, but we don’t have nearly enough. The current school psychologist to student ratio in this country is roughly 1,400 to 1, while experts say it should be at most 700 to 1. That’s a gap of about 35,000 to 60,000 school psychologists. Teachers too often end up having to fill the gap, taking away from their time focusing on teaching. I will make an unprecedented investment in school mental health professionals in order to double the number of psychologists, guidance counselors, nurses, social workers, and other health professionals employed in our schools, and partner with colleges to expand the pipeline of these professionals.

This way we can focus on investing in prevention in our schools and ensure that behavioral and emotional challenges can be addressed by health care professionals, and not our criminal justice system. And, I will restore the Obama-Biden Administration guidance to help schools address the high number of suspensions and expulsions that disproportionately impact students of color and students with disabilities.

There is no doubt we need a better system of care for the mental health needs of adults and children. According to the National Alliance on Mental Illness, ”individuals living with mental illness experience recovery through a combination of community services, medication, peer
support, housing, education, employment and other supports.” When people have access to all appropriate treatment options they, along with their doctors or other providers, can decide what works best for them. In Medicaid, integrating mental health and addiction treatment into primary care must be a priority. The stigma and discrimination against people with mental illness prevent millions from seeking and receiving effective treatment. We can and must do better.

*The following responses are from candidates who are no longer running

Michael Bennett

Michael would work to integrate mental health with other primary care services to ensure that adults and children are screened and treated for both physical and mental health conditions. He would remove regulatory hurdles for providers who treat people with mental illnesses, and direct his Administration to enforce mental health parity so that health plans are required to cover mental health and substance use disorder treatment at the same rate they would cover medical or surgical benefits. Additionally, Michael’s public option, Medicare-X, includes mental health and substance use disorder treatment as an essential health benefit. We also have to protect Medicaid and Medicaid expansion for those who rely on those programs for mental health treatment.

*No longer running

Cory Booker*

I believe healthcare is a human right, and that includes mental health care. Right now, one in five Americans are affected by mental health conditions, and more than half of those affected are left untreated, either because they cannot access care or because they do not know that they need it. This is not just devastating for the families left coping with these illnesses unassisted, but it is devastating for our economy too. The National Alliance on Mental Illness (NAMI) estimates that untreated mental illnesses cost about $100 billion a year in lost productivity. We must expand what we mean when we talk about healthcare and healthy families and healthy communities.

As President, I will fight for Medicare for All, which would allow every American to be able to see mental health providers like psychologists and psychiatrists without incurring any out-of-pocket costs. I will also immediately end efforts to repeal the Affordable Care Act, and work to strengthen and expand it with every tool I have. It is past time we make access to affordable health care–including mental health care–to every person in this country.

*No longer running

Steve Bullock*

I am deeply concerned that there remains a stigma around mental health and that in turn leads to inadequate services and treatment. There also are significant disparities around mental health that impact communities of color — for example, NAMI reports that African Americans and Hispanic Americans use mental health services at about one-half the rate of Caucasians and Asian Americans at about one-third the rate. We see the impact of stigma in other ways, from the appalling number of veteran suicides to an elevated risk of suicide attempts among lesbian, gay, bisexual and transgender youth.

According to NAMI, approximately 10% of children and adolescents have mental illnesses, yet only 20% of those are identified and receiving services. Early identification and intervention is key. Thus my administration would:
– Increase funding opportunities for school-based mental health screening and interventions, anti-bullying programs and de-stigmatization efforts.
– Work with states that have yet to pass Medicaid expansion to encourage passage. Medicaid expansion makes a meaningful difference in early mental health diagnosis, and treatment.
– Increase funding and support for tele-health options for areas underserved by mental health professionals.
– Lift the ban on CDC gun violence research. With 60% of suicide deaths involving a firearm, we need access to research and red flag laws.
– Finally, further research is needed as we don’t have a great detail about the efficacy of targeted suicide prevention programs. More research and program evaluation dollars are needed to determine best practices and help non-profits, state and local governments and even federal agencies determine whether we are reaching at-risk people effectively.

* No longer running

Pete Buttigieg*

My vision is to normalize mental health and addiction services by better integrating them into our clinical settings as well as our community settings. Mental health is crucial for our health – it’s also at the heart of many other issues, from opioids and gun violence to decreasing life expectancy. As President, I will invest in prevention, early detection, and treatment of mental health, and make it a priority for my overall health agenda.

To start, I believe that we first must create an actual system of care – one where people seeking mental health care do not have to work so hard to find help. The data is troubling – most people who seek care are not able to receive that care. In 2019, this is unacceptable. We will prioritize investments in mental health services, create comprehensive coverage options so that people can afford care, including mental health care, and create incentives that encourage more robust and tighter coordination of care.

Second, I believe that we must work with our educational system, a key partner in this effort. I will partner with schools, colleges, and universities to educate students on the symptoms of mental illness and provide resources to students at risk. I will ensure that schools and campuses have adequate support for onsite mental health resources and services, and that when possible, we provide onsite trainings so that our students know how to talk to and support each other about these issues.

Third, let’s support our law enforcement officers and jail staff who are often the first responders to individuals who are undergoing mental health crises. I will work with Congress to dedicate additional resources for initiatives to help prevent mental health episodes from reaching a crisis point, including successful models of community-based care, mental health and drug courts, and increasing resources for specialized mental health units in our prisons as well as transitional housing that provides support and treatment upon release.

The opioid epidemic in some ways is symptomatic of a deeper mental health and addiction crisis in our country. We need to increase our efforts to enforce mental health parity laws, encourage medical providers to use team-based approaches to pain, not just rely on prescription opioids when not clinically appropriate, and to increase the number of effective treatment programs for opioid use disorder.

I also believe that we must invest heavily in treating veteran mental health and supporting veterans as they return from overseas and reintegrate back into the community as our fellow citizens, friends, neighbors, and family.

Finally, it is crucial that we work to end the stigma around mental health. This starts with structural elements like ending discrimination at work and in schools. I will focus on ensuring that individuals with mental health needs can access the support and resources they need in a timely manner to live empowered, meaningful lives.

New Hampshire, like many states, has an opportunity to help lead in mental health transformation. Thankfully, it appears that New Hampshire is in the process of bringing forward a more complete vision for mental health and addiction through its 10-year mental health plan, which calls for many items consistent with our approach to mental health and addiction – a focus on access for individuals across the full continuum of care, the importance of remaining local, addressing our mental health workforce problem, and on integrating mental health services.

*No longer running

Julian Castro*

My expanded Medicare system covering all Americans must include robust mental health coverage and should also be paired with expanded support to train new mental health professionals, provide caregivers pathways to remain in their communities if trained there, and boost training for individuals interacting with mental health patients in their communities–such as physicians, social workers, and police officers.

Our mismanagement of mental health also becomes a serious problem in regards to policing. That is why I also support promoting alternative responses to 911 calls by establishing partnerships between mental health units and first responders and encouraging community-led trainings for police departments to emphasize non-violent de-escalation.

*No longer running

John Delaney*

My universal health care plan includes a requirement for mental health parity to ensure that mental health needs receive the same care and attention as physical health needs. I will also increase the number of mental health professionals in schools and expand telehealth options for mental health care in rural and underserved communities.

*No longer running

Tulsi Gabbard*

We have a mental health crisis in this country. Improving access to mental health will be a substantial part of our plan for healthcare and we will work to ensure all communities; rural, urban, and suburban; have an adequate number of mental health providers.

*No longer running

Kirsten Gillibrand*

Insurance coverage for behavioral health services is critical to the health of all Americans and to our ability to address the inadequate access to mental health services that communities across the country are struggling with. I am an original cosponsor of the Behavioral Health Coverage Transparency Act which would hold health insurers accountable for providing adequate mental health benefits and increase transparency for consumers seeking coverage for mental illness and substance use disorders.

I have been a consistent advocate to ensure that people get access to the care they need. I have cosponsored the Disability Integration Act since 2016, and I support its vision of home and community-based care, and not requiring unnecessary institutionalization. I have also fought for funding for Community Mental Health Block Grant to improve community-based services. Physical and mental health outcomes are better for patients that live in their own homes. I opposed Republican efforts to repeal the Affordable Care Act, gutting the mental health services it guarantees.

I believe it is important that we improve access to mental health services for children by expanding services at school. I voted for the Every Student Succeeds Act which provides funding to support mental and behavioral health. We need to be funding these programs and building on them so that we are getting children the help they need early on which we know is of critical importance to mental health outcomes.

I have been the leader on creating a nationally Paid Family and Medical Leave plan, to ensure that family members and one’s self, can take the time they need away from work without losing a paycheck. The FAMILY Act would provide up to 12 weeks of 66% wage replacement in the event of serious personal or family medical emergency.

*No longer running

Kamala Harris*

In America today, one in five people experiences a mental health incident in their lifetime. This is an epidemic that too many are left to face on their own. To address it, I believe we must drastically increase affordability and access to mental health care in all communities.

First, we need to ensure mental health services are affordable for every American, not just a luxury for the wealthy. That’s why I support Medicare for All, which will provide comprehensive coverage for mental health and substance abuse treatment services with no copays, premiums, or deductibles.

But ensuring mental health services are affordable isn’t enough. We also must ensure every American can access those services no matter where they live. Today in America, more than 120 million people live in an area with a shortage of mental health professionals, including many in New Hampshire. That’s why I introduced the Mental Health Telemedicine Expansion Act, which would utilize telemedicine to ensure Americans in rural and under-served areas can receive care. I also introduced the Mental Health Professionals Workforce Shortage Loan Repayment Act, which would incentivize mental health professionals to practice in those areas.

*No longer running

Jay Inslee*

Meeting the mental health needs of adults and children isn’t just a challenge in New Hampshire — it’s a nationwide problem. According to the National Alliance on Mental Illness, employment rate for people living with mental illness are only approximately 20%. Many of those people aren’t receiving the support they need to succeed and are at higher risk of facing additional challenges.

As governor, I called for a five-year transition away from outdated models of providing mental health care to a community-based hospital model. This year’s budget delivers by investing nearly $300 million in building and expanding beds and care facilities, in a new behavioral-health teaching hospital, and new community-placement facilities. But investments are just part of the solution, and I’ve also signed legislation improving access to mental health care by integrating physical health, mental health, and addiction treatment for Medicaid applicants, instead of having to navigate separate systems.

I believe that the approach we’ve taken in Washington state is a model for America. Our mental health laws and regulations are outdated and are doing a disservice to many who would otherwise, with better written laws and evidence-based regulations, lead happy and productive lives. As president, I pledge to work with stakeholders to jump start reform of those laws and regulations.

* No longer running

Amy Klobuchar*

Senator Klobuchar’s dad struggled with alcoholism and she saw the toll that substance use disorders and mental health can take on families and communities. She was the first presidential candidate to roll out a comprehensive mental health and addiction policy. And as President, Senator Klobuchar will launch new prevention and early intervention mental health initiatives, enforce mental health parity, expand access to health care delivery and treatment beds for people with mental illness, and give Americans a path to sustainable recovery. Her plan will ensure that everyone has the right — and the opportunity — to receive effective, professional treatment and help.

*No longer running

Beto O’Rourke*

A system of services to support people with mental illness must go beyond the concept of focusing solely on the individual, but should also address family, school, home, work, and community conditions, as well as economic or environmental factors. Beto will call for additional funding for states’ mental health and substance use programs and services; pass universal healthcare with parity for mental health services; and oppose any attempt to cut Social Security Income and Social Security Disability Income. Beto will work to address the lack of mental health professionals and enforcement of parity in mental health and substance use services and treatment, and the culture of stigma that prevents many individuals from seeking needed treatment. In creating a detailed, national plan for increased access to mental health care, Beto will consult with impacted individuals as stakeholders; state and community-based organizations; national disability advocacy and civil rights organizations; mental health professionals; teachers; faith leaders; veterans; criminal justice reform advocates; and organizations whose successful mental health and substance use initiatives, research, and best practices to inform how we can vastly improve upon the present complex systems of services, supports, and treatments necessary to improve lives and ensure civil rights of people with mental illness.

* No longer running

Tim Ryan*

As a nation, we must realize our mental and emotional health is just as important as our physical health. I strongly believe everyone should have access to quality and affordable healthcare, and this includes mental health services. The Affordable Care Act (ACA) added mental health and substance abuse treatment as one of the essential health benefits, and federal parity laws protect that coverage by saying it must be offered at the same level as other medical or surgical services. But unfortunately, many insurance companies have found ways to add additional red tape for those needing mental health services. I believe we need to add an enforcement mechanism to strengthen federal parity laws so that everyone truly has the ability to access mental health services.

* No longer running

Bernie Sanders*

We are experiencing a crisis in mental health treatment in this country. Bernie’s Medicare for All plan would address this crisis by providing comprehensive coverage for mental health and substance abuse treatment services as well as prescription drugs. Mental healthcare, under Medicare for All, will be free at the time of service, with no co-payments that can be a barrier to treatment.

*No longer running

Joe Sestak*

Too often mental health is considered an issue apart from our broader healthcare system. But we know that mental health is critical to overall health and well being. We also know that our mental health system is failing. While some 43 million Americans suffer from a mental health condition, only 43% of them have received some form of treatment, according to a report from Mental Health America (MHA). The same report found that over 76% of youth with severe depression — some 1.7 million kids — do not get the treatment they need. It’s no wonder that both suicidal ideation and major depressive episodes among our youth are increasing.

Shockingly, nearly half of all psychiatrists refuse to accept Medicare or Medicaid patients, or even patients with private health insurance, instead preferring to see only cash-paying patients. While this is their right, it is incumbent on policymakers at the state and federal level to provide incentives to mental health professionals to do the right thing and take on the patients who need their help the most. We must also increase the number of hospital beds available for inpatient psychiatric treatment, currently at the same level as it was in the 1850s — though our population is roughly 10 times larger today.

The federal government is already required to play a role in assuring that mental health and addiction are covered by health insurers under the Mental Health Parity and Addiction Equity Act (MHPAE) — which requires that restrictions and insurer’s requirements for coverage of mental health and substance use disorders are no more restrictive or onerous than those set for other medical and surgical benefits — but the Act is largely unenforced. Unfortunately it was written without a mechanism to monitor and evaluate its effective implementation, so it must be amended and updated as soon as possible — and then we must enforce it, with the federal government having a significant role in overseeing the enforcement by the states of equity between mental and physical healthcare. The ACA did improve coverage for behavioral health patients, we still have a long way to go but the parity protections of the MHPAE do not extend to Medicare, traditional Medicaid, or certain bare-bones catastrophic coverage plans currently offered. We must extend parity protections so that people in such plans are also able to access mental health and substance abuse treatment.

* No longer running

Tom Steyer*

Every American deserves the Right to Health Care. The ability to access the care they need is foundational to our sense of safety and possibility. It is key to our economic prosperity. I understand that different communities face different health care needs. For too long, tribal nations, women, veterans, rural communities, people with disabilities, and communities of color have been denied a full suite of health care services.

Mental health parity in a key component of overall health for Americans. Whether one is struggling with addiction, cognitive disability, or Post Traumatic Stress Disorder, my administration will allocate $100 billion specifically to mental health services. If you are sick, or need assistance or professional care, you will get that under my plan.

*No longer running

Eric Swalwell*

Mental health must be an integral part of healthcare, with quality, affordable services available to all Americans without exception. Too many people with mental health issues end up incarcerated, or homeless, or in substance addiction; stronger diagnostic and clinical services for all would help avoid these outcomes. This requires more funding and resources across the board.

I’m the only 2020 candidate proposing a massive public investment in finding cures and more effective therapies in our lifetime for the deadliest and most debilitating diseases and illnesses that ail us. In Congress, I’ve urged better funding for the National Institutes of Health. We need to be able to look ailing Americans in the eyes and truthfully tell them we’re doing all that we can to help.

Providing housing for those who are mentally ill and homeless is a key component of recovery. Housing paired with assisted outpatient treatment centers is proven to reduce homelessness, arrests, and hospitalization of the mentally ill.

I would reform Medicaid law to make it easier to reimburse hospitals for treatment, and to remove rules that block payment for mental and physical health care delivered on the same day.

I co-sponsored the bipartisan Helping Families in Mental Health Crisis Act, elements of which were included in the 21st Century Cures Act that President Obama signed into law in December 2016. The 21st Century Cures Act strengthened parity regulations requiring insurers to cover mental health treatments in the same way as physical medical treatments. It also included funding for community mental health resources, suicide prevention and intervention programs, de-escalation training for law enforcement, and a demonstration program in which psychiatry residents and other mental health clinicians practice in underserved areas.

The final bill, however, did not include provisions to reform the Health Insurance Portability and Accountability Act (HIPAA) of 1996 to give families more power to intervene in the care of loved ones with mental illnesses; I would pursue such reforms as President.

* No longer running

Elizabeth Warren*

Nearly one in five U.S. adults experience mental illness in the United States in any given year and only half of adults in New Hampshire receive any form of mental health treatment. In 2017, I led the fight to prevent budget cuts to the Mental Health Block Grant and secured an additional $160 million for the program. I also urged appropriators to designate $1 billion to mental health programs through the Substance Abuse and Mental Health Administration. And I fought Republican efforts to repeal the individual mandate, strip health care coverage from millions of Americans, and reduce access to health care for people with disabilities.

Americans have a right to equal health care coverage for physical and mental illness. Despite the widespread need for mental health services, the number of individuals across this country that are denied mental health services is alarming: in New Hampshire, less than half of those living with mental illness receive any mental health services. That’s why I introduced the Behavioral Health Coverage Transparency Act, which would hold insurers accountable for providing adequate mental health benefits, empower patients, and ensure Americans receive the protections they are guaranteed by law. I’ve also worked to hold the Health and Human Services Department accountable for improving insurers’ compliance with mental health parity laws through an online consumer parity portal.

Supporting mental health services is also imperative to fighting the opioid epidemic — especially in states like New Hampshire, which has an opioid death rate that is more than twice the national average. We need to use every tool in the toolbox to confront this epidemic, which means dedicating sufficient funds to mental health services. My CARE Act would ensure access to mental health services and help provide critical wraparound services like housing support and medical transportation for those who need them.

Finally, I believe that we need to do our best to make sure that people who are incarcerated are treated with basic dignity and respect — including those with mental illness. These individuals should have a chance to emerge from their incarceration as intact human beings who are ready to come back to their communities and make a real contribution. That’s why I led appropriations letters to request robust funding for medication-assisted treatment for individuals with substance use disorders in federal prisons, state correctional facilities, and post-correctional reentry programs. I also joined Senator Markey in requesting a GAO study of how substance use disorders are addressed by the Bureau of Prisons and state correctional facilities.

*No longer running

Marianne Williamson*

Marianne Williamson sees a crisis in mental health in the United States that is reflected in part, in the anxiety of our population, including unacceptable rates of suicide, substance abuse and addiction and a health care system which is really a sickness care system, not truly a health care system. First, health care, including treatment for Mental health, is a right and should not be a privilege reserved for a few. Marianne favors a robust Universal health care system which ensures every person has access to affordable, high quality, portable health care. Mental health care should be treated on par with Physical health care. Most importantly, Marianne Williamson’s Presidency will address the constellation of underlying and connected challenges to the genuine pursuit of happiness guaranteed by our founding documents.

*No longer running

Andrew Yang*

My Medicare for All system would cover all mental health issues. I’d also invest in remote assistance programs to provide care in areas where it isn’t available and encourage people to go into mental health professions. Licensing changes could make certain services more widely available. I will also continue to talk about raising a son with autism throughout my term in office. And I’d have a White House psychologist on staff for all members to destigmatize treatment.

*No longer running