Election 2016: Where the candidates stand

While November 8 might seem like a long way away, the presidential hopefuls are probably wishing for more time on the campaign trail. Most Americans believe it’s going to be an especially heated debate season with high emotion among supporters on both sides. Former Senator and Secretary of State Hillary Clinton, who’s running on the Democratic ticket, and billionaire business owner Donald Trump, who’s running on the Republican ticket, are sharply divided on a number of issues, including several that behavioral health leaders are watching.

In this election, the Affordable Care Act (ACA), policies to address the opioid crisis and general attitudes toward behavioral health concerns are top of mind for industry professionals. Experts in the field stop short of endorsing either candidate, but many are open about what they’re watching in the months ahead and how to evaluate what the next administration might look like.

Carol McDaid, principal of Capitol Decisions, says in the coming weeks, industry leaders should watch the debates on television and listen for relevant keywords in the campaign rhetoric.

“What is an adequate response in some of their remarks to the opioid epidemic, and do they use the words ‘treatment and recovery?’ Those are bellwether words to be on the look out for,” McDaid says. “The analysis of speeches afterwards are worth looking at to see if key issues that our field has been working on come up.”

Hillary Clinton

Democrat

Many believe Clinton’s experience in politics and healthcare reform will be her strong point. However, the main drivers behind unfavorable ratings for Clinton speak to larger campaign narratives that define her as “untrustworthy,” according to a survey by Morning Consult. Her challenge might be to win over those who question her authenticity.

In January, Clinton announced her proposal to tackle the addiction crisis in the United States, a policy that would cost an estimated $10 billion over 10 years. Some $7.5 billion would be dedicated to state/federal partnership models that offer incentives for states to work on five goals identified in the proposal, such as increasing access to naloxone and expanding the addiction-treatment workforce. In a matching program, $4 would be provided by the federal government for every $1 each state provides for the effort. Another $2.5 billion would be added to substance-use disorder block grants. It isn’t clear where the $10 billion will come from.

“It springs back to her days as first lady where she was one of the architects of healthcare reform at that time,” says Mark Dunn, policy advocacy representative for the National Association of Addiction Treatment Providers (NAATP). “This is not new to her. As someone who supports the continuation of ACA and all it does for addiction treatment, I think her approach is at least more thorough and comprehensive and probably embraces our broader member perspective.”

Clinton staffers did reach out to addiction professionals in advance of structuring the plan, and her campaign has indicated the opioid crisis is part of her agenda.

“Clearly Clinton has a leg up on this one because we’ve seen her in action, and she has produced a detailed policy stance on addiction,” says Linda Rosenberg, president and CEO of the National Council for Behavioral Health. “Our staff here have talked to her advisors on mental health and addiction, and she is focused on details, not just statements.”

McDaid says it’s been a pivotal year for addiction policy considering the number of bipartisan bills passing though Congress.

In terms of other healthcare topics, Clinton says on her official campaign site that she will continue to defend the Affordable Care Act against Republican efforts to repeal it, with a focus on addressing costs—something most observers believe ACA failed to accomplish. The growing cost of prescription drugs is an issue she has publicly vowed to work on, noting that three-quarters of Americans believe prescription drug costs are unreasonable.

As of this writing, Clinton did not appear to have a formal position on the use of marijuana recreationally or for medical purposes—something clinical leaders might be watching.

She has proposed allowing individuals as young as age 55 to sign up for Medicare, and the creation of a “public option” health plan that aims to be more affordable for consumers. It would not be the single-payer model that candidate Bernie Sanders had touted but more like a competitor to commercial insurance plans.

The cost of Clinton’s proposed Medicare measure is uncertain.

In July, the Clinton campaign also announced a new healthcare proposal to expand funding for federally qualified health centers by $40 billion over the next 10 years and to make the support mandatory—not subject to appropriations.

Rosenberg says Clinton has put forth more than just rhetoric on a number of healthcare issues, including proposals for policies that could increase treatment capacity or redesign reimbursement models.

“Those are all things people in healthcare are interested in, and she certainly has opinions and positions,” Rosenberg says.

Dunn says in the future, he’d like to see new measures to enforce parity laws for addiction treatment. While there is a federal task force conducting listening sessions and preparing a report on parity in real world practice due out this fall, he will be interested in hearing the candidates’ reactions to the findings.

Donald Trump

Republican

Supporters of Trump are in favor of his take on protecting the United States with tighter borders and strict immigration policies. They agree with his clear message on Second Amendment rights and prosecuting violent criminals.

Attitudes behind the unfavorable ratings for Trump define him as “racist,” according to the Morning Consult survey. Critics also point to Trump’s flippant attitude when asked direct questions as well as his remarks early in the campaign about women and Latinos. His biggest challenge might be convincing voters he is capable of running the country in spite of his lack of experience, having never held an elected position.

In terms of healthcare, day one of a Trump administration would include asking Congress to immediately repeal ACA, according to his campaign website.

“It is a potential concern,” McDaid says. “You have to have both a Republican in the White House and a Republican-controlled House or Senate for that to happen, and even then, it is not guaranteed.”

And according to Rosenberg, the promise of repealing ACA on day one is unfounded. No newly elected president would be able to negate a major piece of legislation in one fell swoop. However, apart from the timing, she is concerned about what a repeal of ACA would look like. More than 24 million people have gained insurance coverage under the law.

“It’s hard to take away benefits people already have,” Rosenberg says. “I hope in a quieter time, Congress will think carefully about things we can improve upon rather than things we can take away.”

But keep in mind that guaranteed Medicare coverage became law in 1965, and Congress still debates the details of how to run the program to this day. The same is true for Medicaid and virtually every other program that involves federal spending. Rosenberg says there’s no time to waste on forcing a repeal of ACA, but rather, the legislative work should be on revising implementation guidance to improve quality and reduce costs—regardless of who gets elected.

Trump also says he would require price transparency from all healthcare providers, which would allow consumers to shop around to find the best prices. Medicaid—which many behavioral health providers rely on for funding—would be modeled as a block grant under his plan as well. Trump’s campaign site calls for reform of the mental health programs and institutions and hints at helping families get information about loved ones but stops short of saying it will change HIPAA regulations.

When considering Clinton’s 10-year plan to address addiction and nothing comparable from Trump thus far, there’s clearly an imbalance on the available information to compare the two candidates on the issues, experts say. While addiction has remained a nonpartisan issue among politicians, Trump has proposed few specifics on his strategy to address it. His public statements have generally focused on thwarting the supply of drugs entering the country from Mexico by building a wall. In a video on his campaign website, he says, “And the people that are in trouble, the people that are addicted, we’re going to work with them and try and make them better.”

NAATP’s Dunn notes that Trump has appeared to be supportive of addiction treatment in the past.

“Miss USA had addiction problems, and he did send her to treatment,” says Dunn. “So based on that, we are hopeful he is somewhat understanding and supportive that treatment works, but we don’t know beyond that at this point.”

Tara Elizabeth Conner, Miss USA 2006, tested positive for cocaine, heroin and crystal meth after earning the pageant crown, but was allowed to retain her title if she agreed to treatment. “I’ve always been a believer in second chances,” Trump said at a press conference. Trump has owned the competition since 2002.

Dunn says addiction is an issue voters care about, and he’s hopeful that the candidate will provide more information as the weeks go on.

Additionally, Keith S. Whyte, executive director of the National Council on Problem Gambling, believes addiction treatment professionals might be concerned about the casino ownership within Trump’s portfolio of business. He says it’s common knowledge that Trump casinos in several states have gone bankrupt, but it’s less clear how responsibly run the establishments have been.

“Anybody who operates a casino has an ethical and economic obligation to provide responsible gaming programs and services for employees and customers and also to contribute to problem gambling prevention treatment efforts in the community, for the general public,” Whyte says. “To my knowledge, Trump appears to just meet the minimum. They did what was required and not more.”

Whyte says the advocated approach is to do right by the customers and employees of the gambling establishment but even more so to be a good corporate citizen.

“Not only are you often reaping windfall profits, but gaming is known to be addictive for a percentage of your customers. And it has ripple effects in the community and nationwide,” he says.

The National Council hasn’t had contact with any Trump advisors on behavioral health issues so far but has spoken with Clinton advisors.

“I don’t know who his policy advisors are in our space of mental health and addiction,” Rosenberg says. “I’ve not met them. But that doesn’t mean he doesn’t have them lined up. We first have to demand attention to healthcare issues and see how specific his campaign can get, including the larger party platform. It’s a big unknown, and that’s where we have to have some pressure.”

Industry shift

It stands to reason that there are more Democrats among behavioral health professionals than Republicans, but as the industry sees greater investment interest, the field could be more balanced than in the past.  McDaid cautions that the industry shouldn’t jump to conclusions today or in the first phases under a new administration, whether Democrat or Republican.

“There’s a nice mix of Republicans and Democrats in our industry at the key leader level,” McDaid says. “And we should not presume we know the outcome of the election now or that we only get a good shake on addiction policy and mental health from a Democrat in the White House because history shows that is not the case. [Favorable] laws have been passed by congressional Republicans, and discriminatory laws were passed under Bill Clinton where people did not have access to Section 8 housing or food stamps as a result of their having the disease of addiction—those were all under a Democratic White House.”

She recommends getting involved by supporting appointments of people who are familiar with behavioral health issues as the various agency leadership positions turn over within the new administration.

“The names don’t come from nowhere,” McDaid says.

Rosenberg agrees that no one should assume Republicans aren’t going to consider improvements on health reform. She points to the comprehensive health measures passed in New York under Republican Gov. George Pataki in 1999 that expanded coverage as well as the parity law signed under Republican President George W. Bush in 2008.

“A Republican administration by itself is not a bad thing, but what kind of Republican will Trump be?” she asks. “We don’t know that, and it’s scary.”

Rosenberg advises treatment center owners and operators to be active in political discussions and to attend townhalls and hill days with questions in hand. There’s a lot of policy momentum in behavioral health right now, and many hope it continues.