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The Presidential Election: Time for Behavioral Health Advocates to Speak Out

The next President of the United States can act to improve or to harm the American mental health system. Behavioral health advocates should speak out now to provide the political pressure that will be needed to improve rather than to harm the system.

Preserve The Affordable Care Act

Perhaps the biggest threat to the behavioral health system is the political attack on the Affordable Care Act. So far about 20 million previously uncovered people have gotten health—and behavioral health—coverage through the ACA. At long last, millions of people with diagnosable mental or substance use disorders who could benefit from treatment have insurance to pay for it.

All behavioral health advocates should insist that the provisions of the ACA—including parity—that increase insurance coverage for behavioral health services survive the change in leadership in Washington.

As we do this, let’s stop referring to the ACA as “Obamacare.” We don’t call Medicare and Medicaid “Johnsoncare.” We don’t call Social Security “Roosevelt security.” Why “Obamacare”? All that does is infuriate the people who hate Obama. Bad politics, in my view.

Mental Illness Does Not Cause Homicide

We also need to persistently inform the Presidential candidates that mental illness is not responsible for homicide in America. People with serious mental illness are far more often victims than perpetrators.

Continued reduction of homicide (it has declined 13% since 2000) depends on measures other than forcing people with mental illness into treatment. Gun control, better policing, reduction of poverty and “adverse childhood” experiences, could make a big difference. But more and better mental health and substance use services, much as they are needed, will do virtually nothing to reduce homicide.

It is true that illegal drugs contribute to the homicide rate. But it is their illegality not their use that causes most related homicides.

The real problem of violence related to behavioral health are the 40,000+ suicides every year. 90% of these are completed by people with mental illness. A better mental health system could and should target the terrible problem of suicide.

The Behavioral Health System Must Grow A Lot

Presidential candidates also need to understand that America’s mental health system does not have the capacity to meet the needs of even half the people with behavioral health problems who might benefit from behavioral health care. 60% of people with a diagnosable mental or substance use disorder do not get treatment. That suggests that the capacity of the mental health system should double. But since not everyone with a diagnosable disorder would benefit from treatment, it may be adequate to increase the system by 50%.

That’s a very large and very costly increase. Currently behavioral health services in the United States cost over $200 billion per year. Another $100 billion? Not likely to happen. But it is very important to be clear with the Presidential candidates that proposals currently on the table for a few million dollars here and there are not nearly on the necessary scale for major change, notwithstanding the rhetoric of reform that often accompanies them.

Growth, of necessity, will be incremental, as it has been for the past 50 years. We should not let elected officials get away with the rhetoric of major reform when they are making minor improvements. But let’s also press for the incremental improvements that are possible.

Quality of Care Must Improve

The presidential candidates also need to be clear that most behavioral health treatment in America is not even “minimally adequate.” When it is provided by primary care physicians, as it increasingly is, it is minimally adequate or better less than 15% of the time. When it is provided by behavioral health professionals it is minimally adequate or better less than half the time.

Efforts to build a clinically, culturally, and generationally competent behavioral health workforce including more research, better translation of research into practice, and a far better trained workforce must be at the heart of the push for a mental health system of adequate quality.

Social Dimensions of Behavioral Health

In part because of the increased reliance on health insurance to pay for behavioral health services, behavioral health policy is generally viewed as just a subset of health policy. This is a serious mistake. An effective system of response to behavioral health problems must address (1) the social welfare needs of people with psychiatric disabilities, (2) the response of the criminal justice system to people with behavioral health disorders, (3) the social determinants of behavioral health disorders, and—perhaps most importantly—the need for adequate housing.

The March of Demography

The vast changes in the demography of the United States are almost totally neglected in discussions of behavioral health reform. These changes in the American population are unfolding now and will continue throughout this century.

The “minority” population is growing so rapidly that in a few decades the United States will be a majority minority. We need a far more “culturally competent” behavioral health system in response.

In addition, the aging population is growing so rapidly that in 15 years or less there will be more adults over 65 than children and adolescents under 18. We need a “generationally competent” behavioral health system in response, including a response to the growth of the number of people with dementia far different from the current effort to prevent or cure Alzheimer’s and related disorders by the year 2025. This moon-shot approach rests more on hope than realistic expectations, and in the meantime does virtually nothing for the 5.5 million people with dementia now, a number that will probably double while we are waiting for a biomedical breakthrough.

Shift the Drug Abuse Paradigm

Changing attitudes towards marijuana use and the rising concern about deaths due to heroin and prescription painkillers will give the new President the opportunity to make a major shift away from America’s current policy of criminalizing “illicit” drugs and to a medical model focused on prevention, treatment, and regulated access.

And More

Obviously, a comprehensive agenda for behavioral health reform would be far more extensive than the few items I have noted above. And, of course, some behavioral health advocates may want to emphasize other matters.

Whatever your views, the time to speak out is now. Let’s do it.

Michael Friedman is retired but continues to teach at Columbia University and to write about behavioral health and about aging. He is the founder and former director of the Center for Policy, Advocacy, and Education of the Mental Health Association of New York City. He can be reached at

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