Mental Health Matters: Risk or reward if we create Trump Care? (opinion) |

Mental Health Matters: Risk or reward if we create Trump Care? (opinion)

Andrew Whyman
File photo |

The United States has the best health care in the world … if you can afford it. It’s the most expensive care according to all the research, and definitely not the most efficient care.

But, overall, if you got the dough, or the right employer, you get your choice of the best specialists, the best hospitals, and the most technologically advance care anywhere.

  The Affordable Care Act (ACA), better known as Obamacare, stripped to its essential premise, argues that world class health care, previously available only to some Americans, should be made available to all Americans.

This noble notion meant that millions of Americans who could not pay for health insurance or fee-for-service care gained insurance at a discount or medical care through expanded Medicaid programs. Many Americans view this as a glorious accomplishment.

“Americans without health care die earlier. Most Americans readily grasp this factual reality when thinking about heart disease, cancer or diabetes. Lose the health care provided by the ACA — and die earlier.”

According to the Department of Health and Human Services, more than 20 million Americans gained health-care coverage through the ACA. More than half of these folks gained coverage by expansion of the Medicaid program.

In Pennsylvania alone, a state President Trump won, 129,000 people were newly insured under expanded Medicaid.

If you believe, as I do, that all Americans deserve a decent chance in life, you will applaud the expansion of health care coverage under the ACA.

The ACA has another less heralded but profoundly important component — vastly expanded access to mental health and substance abuse treatment.

While most ACA proponents have understandably chosen to emphasize the expansion of life enhancing and life saving medical care, mandating mental health and substance abuse treatment as “essential services” has greatly expanded treatment.

It has also started to draw in more and better qualified medical and paramedical professionals, commenced a more efficient and effective delivery system by including mental health and substance abuse care in primary care settings rather than in remote, stand-alone locations, and created new synergistic opportunities. 

One exciting example of these changes is the opportunity for mental health and substance abuse courts to increasingly emphasize treatment as a relatively effective and low cost alternative to incarceration.

Another approach avoids criminalization of behavioral and substance abuse problems altogether by partnering with providers as an alternative to criminal booking.

Two examples help to get at the potential of these new services: In Kentucky there has been a nine-fold increase in addiction treatment through Medicaid. In Virginia, 30,000 people are now being treated as compared to 9,000 before the ACA took effect.

To be sure, there are problems with expanding medical care to additional millions of people. For one, medical care is costly, and when the feds and the states provide more of it, the cost of government increases initially.

However, the cost of care will drop over time because preventive and primary care is much less costly than emergency and hospital care. Too bad this truth doesn’t compute with “small government” ideologues.

Another problem is that our health care delivery system has been terminally inefficient for decades, needlessly driving up the cost of health care.

Also, the ACA did little to address the provision of fee-for-service care in the absence of outcome and cost-containment metrics. The result is more unnecessary surgeries, lab tests, procedures, and medication, all unnecessary cost drivers.  

So, go ahead and “Repeal and Replace” Obamacare, but don’t insult the citizen with cheap vaudeville sleight of hand tricks to take away benefits and call it “creating choice,” or “improving access,” or “freedom to choose.”

Put simply, if the ACA is repealed and replaced with a plan that doesn’t provide ALL the benefits currently provided, two things will happen; people will die unnecessarily and crime will increase. Why?

Americans without health care die earlier. Most Americans readily grasp this factual reality when thinking about heart disease, cancer or diabetes. Lose the health care provided by the ACA — and die earlier.

The same is true for mental illness and substance abuse, with an additional ominous caveat; Untreated mental illness and substance abuse leads to more crime, incarceration, court costs, vagrancy, homelessness, family disruption, at risk youth, and all the other downstream effects of ignoring this population.

So, let’s be clear. For all its deficiencies, all correctable by improving the ACA and renaming it Trump Care, repeal without an improved replacement will be costly for society and catastrophic for millions of vulnerable individuals.

Incline Village resident Andrew Whyman, MD, is a clinical and forensic psychiatrist. He can be reached for comment at

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