Democratic presidential hopeful Pete Buttigieg on Friday laid out a proposal designed to combat America’s opioid epidemic while making some of the most sweeping changes in mental health care since the shift from institutional to community-based care half a century ago.
The plan by Buttigieg, who is mayor of South Bend, Indiana, represents an effort to fight an addiction crisis that has already taken nearly half a million lives and has, somewhat belatedly, become a major topic of discussion in American politics.
But Buttigieg wants to do a lot more than simply reduce addiction and the suffering it has brought to wide swaths of America. He also wants to transform mental health care by increasing the number of front-line mental health workers, making sure insurance pays fully for psychiatric treatments and integrating mental health care into physical health care more generally.
Buttigieg’s overall goal, advisers told HuffPost, is to attack mental health as a public health crisis, with the federal government financing local efforts that focus on prevention and detection as much as treatment.
The total cost would be $300 billion over 10 years, advisers said.
“Our plan breaks down the barriers around mental health and builds up a sense of belonging that will help millions of suffering Americans heal,” Buttigieg said in a prepared statement.
Parts of Buttigieg’s policy vision overlap heavily with what some of his 2020 Democratic rivals are proposing. Earlier this week, Sen. Kirsten Gillibrand (D-N.Y.) unveiled a proposal that calls for some of the same steps that Buttigieg’s plan does.
“It’s time for mental health to be taken as seriously as physical health,” Gillibrand wrote in a Medium post introducing her plan.
And although there are some big differences of scale and substance among the candidate plans, all would represent a sharp departure from the policies of President Donald Trump, who has spent much of his first term undermining public programs that pay for mental health treatment and reinforcing stigmas around psychiatric illness.
An Agenda That Experts Endorse
If successful, Buttigieg vows, his plan will make sure that 75% of people who need treatment for mental health problems or addiction get that care ― a dramatic increase from today, when only a small fraction do. In the process, Buttigieg says, his plan could save a million lives within a decade.
Those are lofty goals, obviously, requiring not just enactment of Buttigieg’s entire agenda but also near-flawless implementation ― not to mention a fairly heroic assumption that the multitude of programs Buttigieg wants to fund would prove as effective as their advocates promise.
Still, his general approach is consistent with what experts have recommended for some time.
Today, for example, the gold standard for addressing opioid addiction is “medication-assisted treatment,” or MAT, in which addiction patients take alternatives that satisfy their cravings without producing a high.
MAT used to be a lot more controversial because critics said it didn’t fully “cure” people of their addictions. But there’s now overwhelming evidence of its effectiveness. To increase its use, Buttigieg would take a variety of steps, like requiring that insurance plans cover it fully and enabling more front-line health care workers to prescribe it.
Buttigieg also wants to increase the size of the mental health care workforce, by investing in new training slots and, then, increasing what insurance pays for mental health services. Historically, low insurance reimbursements for psychiatrists, psychologists and other professionals has made it difficult for people seeking mental health care to get it ― or, at least, care that their insurance would cover.
Higher pay for providers isn’t the only reimbursement change Buttigieg has in mind. He wants public programs to pay for “telemedicine” (in which therapists provide care by video connection) and to provide incentives for more integration of mental health treatment into primary care. He also wants better enforcement of mental health “parity” rules, including those in the Affordable Care Act, which mandate that private insurers cover mental and physical health equally.
Though the federal government could make some of these changes directly by changing the way federal insurance programs work or rewriting regulations, a big part of Buttigieg’s plan is to make $100 billion in grant money available to local agencies. The money would be contingent upon the agencies demonstrating, with data, that their programs were effective at reducing mental health incidence or severity.
Buttigieg’s agenda includes other proposals, as well, and together they would represent a significant shift in the way the U.S. handles mental health care ― moving it toward more spending on treatment, greater emphasis on screening and early detection, more integration of mental and physical health, and less stigma of mental illness. Taken together, they could add up to the biggest changes since the efforts at “deinstitutionalization” in the 1960s and 1970s.
“Pete’s plan is hopeful, specific, and comprehensive,” Andy Slavitt, the former Obama administration health care official, told HuffPost via email. Slavitt did not advise the campaign but got a look at the plan before its release and said Buttigieg “turns the page ahead of the current national debate (how to cover more people) and to one of the biggest holes that we have— our deeply underfunded, under-resourced mental health care system.”
Of course, the price tag for doing that would be significant, and, at least for now, the Buttigieg campaign isn’t identifying offsets. But advisers noted that reforms of mental health care, even those that require new spending in the short run, can produce savings in the long run ― whether it’s by promoting more integrated, more efficient medical care or by reducing the incidence of costly incarceration.
“Right now, we are throwing a whole lot of money at jails and prisons ― it’s millions and millions and millions of dollars a year,” Paul Gionfriddo, president of Mental Health America, told HuffPost on Thursday. “We wait for a crisis, until it’s stage four, and respond inappropriately through incarceration.”
A Clear Contrast With Trump
Mental health has never gotten the kind of attention in a presidential campaign that it is getting for 2020.
Sen. Elizabeth Warren (D-Mass.) has put forward an opioid proposal based on legislation, called the CARE Act, that she co-sponsored last year and that advocates have hailed as a model for action. It would require $100 billion in new spending, the same amount that another 2020 candidate, Sen. Amy Klobuchar (D-Minn.) is seeking with her opioid addiction proposal.
Rep. Seth Moulton (D-Mass), citing his experience with post-traumatic stress disorder, has introduced a mental health agenda of his own.
And that’s to say nothing of all the Democrats who have sought to bolster insurance coverage of psychiatric care.
The contrast to the policies of Trump and some of his Republican allies in Congress could not be more stark. Their ongoing efforts to roll back and repeal the Affordable Care Act threaten to defund treatment programs across the country while leaving millions with no way to pay for addiction treatment or other forms of mental health care.
“The presidential candidates are taking early identification and intervention around mental illness seriously and putting it to the forefront of the campaign,” Gionfriddo said. “Which is a big contrast to what we are seeing from the president, which is waiting for crises to occur and then putting people into custodial care institutions.”