Columnist

In response to the school shooting in Florida this week, President Trump declined to name guns as part of the solution to gun violence. Instead, he promised to “tackle the difficult issue of mental health.”

Let’s say Trump does in fact believe that the cause of our gun violence epidemic is not guns but untreated or undertreated mental illness. You would never know he feels this way from looking at his budget.

Trump’s proposed fiscal 2019 budget, which came out earlier this week, cuts hundreds of billions of dollars from Medicaid. Yet Medicaid is a critical source of mental-health services for a large segment of the population.

In 2015, Medicaid covered 21 percent of adults with mental illness and 26 percent of adults with serious mental illness, according to the Kaiser Family Foundation.

A large chunk of Medicaid spending goes toward mental health. As of 2014, mental-health spending represented almost 1 of out every 10 Medicaid dollars spent, according to the Substance Abuse and Mental Health Services Administration (whose budget Trump also wants to cut).


Source: SAMHSA.

Additionally, the Trump budget includes the passage of Graham-Cassidy, the last-ditch Obamacare repeal effort from last year. This bill would, among other things, allow states to waive Obamacare’s essential health benefits. These are the categories of services that individual/small-group insurance plans must cover, such as prescriptions and maternity care. One of those essential benefits happens to be mental-health and substance abuse disorder treatments.

If you think states will continue requiring coverage of mental-health services absent a federal requirement that they do so, take a look at the landscape of individual insurance plans from before the Affordable Care Act. Pre-ACA, nearly 4 in 10 nongroup plans didn’t cover even outpatient mental health:

Even those that did cover mental-health services often severely restricted what was covered. From a Kaiser Family Foundation report:

Among plans with coverage for outpatient mental/behavioral health services, 23% limited benefits for some or all mental/behavioral services to fewer than 30 visits or sessions over a defined period (often a year) and 12% limited it to 12 or fewer.  A small share (about 5%) of plans providing coverage for outpatient mental/behavioral health services provided benefits only for conditions defined as severe mental disorders or biologically-based illnesses or applied limits (such as visit limits) if the illness was not defined as severe or biologically based.  The definitions of these terms varied by state.

This is the world that Trump, and in fact most Republican lawmakers, wish to return to.

If they’re going to blame deficiencies in the mental-health system for why we have gun violence — and to be clear, there are also lots of other reasons to improve access to care for those suffering from mental illness — they should put their money where their mouths are.