Mental Health Stigma in Healthcare

How repeal of the ACA would affect millions of Americans, including veterans.

According to health policy expert Daniel E. Dawes, “The Senate bill is an even meaner bill than the House bill.” Dawes (who was an instrumental force in the drafting of the Affordable Care Act [ACA]) and other mental health advocates are fighting to protect essential benefits currently under attack by Obama opponents, including benefits for mental health and addiction care. “We are likely to see significantly more folks having issues accessing care,” he says, referring to the bill’s plan to roll back the Medicaid expansion. His greatest concern is block granting, which he says could result in close to 4 million people losing their mental health coverage. “This is a huge deal for them as many of them never had access to mental health services until the ACA,” Dawes continues. “We know at state levels, most states, in terms of powerful lobby groups, mental health is treated as secondary in terms of funding. I’m leery of relying on states to do the right thing.” Championing these issues in 50 states instead of just trying to preserve the gains made, Dawes says, will be that much more challenging than on a national floor that everyone has to meet in terms of funding. This, he says, will be an exhausting and expensive endeavor. Mental Health as Inferior “When health care gets a cold, mental health care gets pneumonia,” says Jeffrey Lieberman, MD, chair of psychiatry at Columbia University and New York Presbyterian Hospital and past president of the American Psychiatric Association. “If we cut back on the financing mechanism—reimbursing providers and giving people access to care—it will reduce the number of people who are able to get treatment and, as a result we’ll see the social consequences: more homelessness, incarceration, more people visiting the ER in crisis stages, suicide, addiction, violence.” Stigma in the Military One of the consequences to which Lieberman refers will be the effect on the military and on veterans. Less than half of all U.S. veterans actually receive their health care through the Veteran’s Administration (VA), either because they do not qualify for benefits or live too far from a facility. This leaves nearly one in 10 veterans relying on Medicaid for their health care. If the Senate Health Care bill is passed, this will leave almost 1.75 million veterans without coverage. Given that veterans are at a 21-percent higher risk of suicide than civilians—leading to an estimated 20 suicides each day—the consequences of losing mental health coverage could be devastating. “The military has had a tsunami of mental health-related issues,” says Lieberman. “There have been psychological problems historically, since the Civil War when it was termed ‘shell shock.’” What we now know as post-traumatic stress disorder (PTSD) was not named until the Vietnam War, and it was not until 1980 that it was recognized by the American Psychiatric Association as a diagnosable disorder. “That these conditions are real and exist in the military is difficult for many to accept because of ethos,” says Lieberman. “Any notion of psychological weakness. If you can’t see the wound, it doesn’t exist.” Paul A. Dillon is an advocate for veterans and a member of the Leadership Council of the Kennedy Forum Illinois. Created in 2013 by former U.S. Representative Patrick J. Kennedy, the Kennedy Forum is a national nonprofit organization whose mission is to “seek to unite the health care system, and rally the mental health community around a common set of principles … to break this silence in our civilian, military and veteran communities—to turn around this conversation on mental illness and related pathologies—from something to be ashamed of and hidden, to seeking treatment.” In an article that first appeared in the August 10, 2016 Briefing Notes of the Military Psychology Program at Adler University in Chicago, Dillon wrote,

To date, in many—but, not all—instances in the Armed Forces, mental illness, PTSD, TBI, substance abuse, and the like have been viewed as shameful weaknesses ... as moral failings ... as defects not worthy of a warrior. And, this attitude, unfortunately, can carry over to people who have left the service … our nation’s veterans. Of course, we know, based upon empirically derived, a posteriori, data and analyses, that these pathologies are not weaknesses—they are not moral failings—they are not defects. They are diseases that no one should be ashamed of having ... they are diseases just like cancer and diabetes are diseases. Protecting Mental Health Parity One of the goals of the Kennedy Forum that pertains directly to our veteran community is to protect mental health parity, another piece of legislature that both Dillon and Dawes say is under attack. The Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA or Parity Law) promised equity in the insurance coverage of mental health and substance use disorder care, putting them on par with medical/surgical benefits. “They wanted to mandate it as an essential health benefit, but couldn’t do it then,” says Dawes. “For the first time in our nation, the ACA mandated mental health and addiction were essential benefits, and expansion of the parity rule to these plans and beyond. This was a huge victory.” But years later, mental health and substance abuse parity to the full extent of the law is still not a reality, and too many Americans continue to be denied care when they need it the most. “To fulfill the promise of the Parity law,” says Dillon, “we must hold health insurance plans accountable to comply with the letter and spirit of the law.” By implementing the proposed provisions, our government will be hurting the very people who have sworn to serve and protect us. How is that fair? “If we are not mindful of the history of mental health reform,” says Dawes, “I believe this is the last opportunity to preserve the gains we have made. If Republicans are successful in dismantling [the ACA] I believe we won’t ever, in our lifetime, regain what we’ve lost.” This article first appeared in The Huffington Post.

References Dawes, D. (2017, June 30). Phone interview. Lieberman, J. (2017, June 30) Phone Interview.

This article was originally published on Psychology Today.