Mayor Pete Buttigieg (D-South Bend, IN)

1. Suicide is the 10th leading cause of death in the US and the second leading cause of death for American youth. Every day, 20 Veterans die by suicide. What steps will you take to prevent suicide?

Suicide prevention is grounded in community and support for the conditions that improve quality of life and well-being. Along with robust programs, such as Zero Suicide, and policies like limiting access to lethal means, from guns to medications, our campaign also believes in the importance of focusing on public health and prevention to address suicide. We believe that we should provide community supports to veterans to improve connection and belonging, while simultaneously working to increase access to services when needed. To address suicide with agencies and organizations such as the Department of Veterans Affairs (VA), we must increase and enhance engagement. As highlighted in the question, 20 veterans die by suicide in the United States each day, and we know that 14 of those veterans were not receiving care from the VA. We must change this because access to care through the VA can help. This will require timely onboarding of new mental health clinicians so that there are sufficient clinicians to address the need. Our veterans have made significant sacrifices for our country–we cannot let them down. We must develop communities that can welcome them home with jobs and opportunity, as well as a robust and effective VA system that can take care of their mental health needs.

2. Every hour, eight people in America die of drug overdose, from opioids and increasingly from other drugs as well. What would your administration do to turn the tide on the addiction crisis?

First, we would address addiction and the opioid epidemic for what it is: a public health crisis. My Administration would recognize that the opioid crisis is undergirded by broader problems–including issues of mental health and addiction, but also of pain and suffering, trauma, loneliness, and belonging. We must look upstream to determine what caused this crisis in the first place, how we can address it, and most importantly, how we can prevent it from ever happening again. In addition, we must recognize that this issue is intergenerational–we cannot simply put out today’s fire without working to prevent tomorrow’s fire. Second, we would expand access to medication-assisted treatment (MAT) for opioid use disorder. MAT is the gold standard for opioid use disorders, and the three FDA approved medications to treat opioid use disorder–methadone, buprenorphine, and naltrexone–are currently underutilized. We will increase access to opioid use disorder treatment medications for communities in need, as well as the number of physicians and advanced practice clinicians able to prescribe buprenorphine, in particular. We will work with states to increase access to 1 MAT in correctional institutions, while encouraging Medicaid programs to directly coordinate with jails and prisons on discharge and re-entry programs with MAT services. Finally, harm reduction programs will be part of our response to the opioid and injection drug use crisis. In particular, we will increase access to Syringe Services Programs (SSPs) for people who inject drugs, to reduce transmission of HIV, viral hepatitis, and other infectious diseases associated with needle sharing, as well as deploy interventions such as naloxone that can reverse opioid overdose.

3. Rates of anxiety, depression and suicidal behavior are all rising among our teens and young adults, but the time from first symptoms (usually around age fourteen) to treatment continues to be almost a decade for many people. What would you do to make sure that more individuals get the help they need when they first need it?

It’s hard enough to be a teenager – the fear of going to school, coming out to your friends, or disclosing issues of mental health or addiction only adds to the stress. We must create a culture of acceptance earlier in a person’s mental health journey, in which they are supported, have access to help and resources, and can learn the skills necessary to maintain a healthy and functional life. Early intervention is the key to addressing mental health for our teens. The research is clear: the more we can do early, the better in the long run for the teen. Preventing and addressing adverse childhood experiences is critical. When teens are exposed to risk factors such as trauma, it is more likely that their mental health will be negatively impacted. Our approach will better integrate mental health services into the places that teens and young adults visit–places like schools, pediatric practices, and other health care settings. This strategy holds the promise of identifying and treating young people sooner to create a lasting, positive impact on their mental health. Finally, we must ensure that our young people know how to talk about mental health with each other. In my National Service Plan, I propose the creation of a Community Health Corps, which would help youth learn how to better talk to peers about mental health and addiction.

4. Our nation is experiencing a shortage of mental health and addiction care providers—including both traditional mental health professionals and paraprofessionals like certified peer support specialists and recovery coaches—and other barriers to treatment, especially in rural and underserved areas. What is your position on improving access to mental health and addiction care for these communities?

To meaningfully address our mental health and addiction care provider shortage, we must be creative about who does what, where, and for whom. Democratizing knowledge about mental health, through initiatives like the Mental Health First Aid program, is a step toward enabling each of us to address mental health within our own families and communities. We also need to better distribute our current mental health workforce so that the right people are in the best places for those seeking care, such as schools and primary care settings. As noted, we must dramatically reduce provider shortages in rural and underserved areas. My recent rural health plan shares how my Administration will accomplish this by increasing Medicare reimbursement rates and by expanding the Public Service Loan Forgiveness Program, 2 the National Health Service Corps, community paramedicine programs, and the Conrad 30 waiver program to attract immigrant doctors. Without a robust mental health workforce that is well integrated across health care and community, we will continue to have challenges increasing access to mental health and addiction support. My forthcoming mental health and addiction policy plan will provide additional details on proposed solutions to the workforce shortage and better clinician integration. For now, I will outline immediate steps that can be taken with the current workforce. For example, a new Administration could amend the Controlled Substances Act to allow prescribers with controlled substances licenses to prescribe buprenorphine without additional DATA 2000 waiver training. This would enable frontline clinicians to better combat addiction. In addition, I would support technology that enhances access to mental health and addiction consultation, such as Project ECHO, and also allow for technology to be a vehicle for intervention (e.g., telepsych in rural areas).

5. For many people, the initial point of care for their mental health condition or substance use disorder begins with the criminal justice system. What is your plan to advance crisis intervention services in the community while also providing treatment and alternatives to incarceration for those already involved in the criminal justice system?

For too long, we have criminalized mental health and addiction in this country. Because of inadequate investment in a true community mental health system, mental health needs often go untreated, which has led many to experience homelessness and incarceration. Many with severe mental health needs often encounter law enforcement more frequently than medical treatment, and with no true system to take care of these individuals, they are often housed in jails and prisons. This must change. My forthcoming mental health and addiction plan outlines clear ways to reinforce a community approach to mental health–not only to invest in community strategies that tackle mental health and addiction, but also to create a vision for a more integrated approach to care. As I outlined in my Douglass Plan, an unjust criminal justice system means an unjust health care system. We will remove the Medicaid exception for incarcerated people, as currently correctional health care is neither paid for by federal health dollars, nor subject to the quality controls and oversight that accompany those funds. There is therefore a separate and lower standard of care in jails and prisons with deadly implications for people suffering from issues of mental health, opioid use and substance use disorders, and chronic illnesses. This problematic rule also creates avoidable gaps in care during re-entry into the community, such that people released from prison are 12 times more likely to die within the first two weeks after release, and up to 130 times more likely to overdose from opioids, as the general population. We will work to ensure that those who are incarcerated receive the same high-quality standard of care that all Americans deserve.

6. The Mental Health Parity and Addiction Equity Act (Federal Parity Law) was enacted in 2008, yet some insurers continue to illegally deny coverage of care for mental health and addiction treatment services. How will you ensure enforcement of the Federal Parity Law?

3 This monumental law aimed to right a wrong – it began a process to ensure that mental health benefits would be at parity with medical/surgical benefits so that people with mental health and addiction needs do not experience discrimination at the hands of health insurers. Sadly, 10 years later, implementation and enforcement has been mixed, resulting in higher co-payments, deductibles, and other “cost-sharing” mechanisms by insurance companies, and therefore, reduced access to, and use of, services by patients. I propose individual and community enforcement of the parity laws through threat of or actual litigation, as well as random audits and financial sanctions for violations. Addressing mental health parity is a core element of comprehensive coverage for millions in our country. My broader mental health and addiction plan will not only highlight the need for parity enforcement, but also for parity in other health plans not currently included in the law.

7. How will you fulfill the intent of the Community Mental Health Act of 1963, a law that meant to ensure that people have access to mental health and developmental disability care within their communities rather than in institutions?

Community is at the heart of good health. Since 1963, our country has not properly invested in or supported a truly integrated mechanism for mental health both within communities and the health care system. This has caused many negative consequences, including the ongoing incarceration of individuals with mental health needs. Because we have not adequately invested in our community mental health system, it lacks sufficient resources to help countless Americans who need care. Ensuring that we properly invest in and integrate the community mental health system with the broader health care system is a much-needed and often forgotten policy goal, which we will prioritize.

8. Poverty is associated with very poor outcomes for people with mental health or substance use disorders, primarily due to lack of secure housing and employment opportunities. What will you do to ensure that income is not a barrier to recovery?

Investing in vital community assets such as housing, transportation, and schools, is foundational to positive mental health and well-being. If we do not address key social factors both upstream–to facilitate prevention–and downstream, to encourage recovery and healing, we cannot address mental health in a comprehensive way. My approach is simple: we must consider community the foundation of success and invest in communities so that they can allocate resources to what matters most to them. For some, this may be housing, for others, treatment. We must recognize that simply closing the treatment gap for mental health, while a worthwhile goal, will never solve all of the challenges people face. We have to do more with community factors. This includes expanding Medicaid services to support key health-related social needs such as housing, employment, and non-medical transportation. And, of course, we must fight poverty itself–a key focus of my policies on labor and wages.

9. People of color, immigrants, Veterans, people living in poverty, people who identify as LGBTQ+, and others have unique needs and challenges as it relates to mental health and addiction. What will you do to ensure that these and other underserved groups have access to the mental health and addiction resources and supports that they need?

We have developed plans for individuals in each of these special populations, to take into account their unique needs. Medicaid expansion is central to improved access and outcomes. There is compelling evidence that people who live in states that have expanded Medicaid have experienced improved physical and mental health outcomes. I will continue to press states that haven’t expanded Medicaid to do so. My forthcoming health plan, including Medicare for All Who Want It, will strengthen access to health services, including mental health and addiction services, for our neediest, especially those living in poverty and people of color. (See earlier questions regarding veterans). For our LGBTQ+ population, we must first recognize destructive practices currently being used in the name of assistance. In particular, my Administration would support outlawing the damaging practice of conversion therapy. While some states have begun to make progress in this space, the Federal Government can support their efforts by naming harmful practices and encouraging states to do more. Moreover, my Administration will reinstate and strengthen civil rights protections for the LGBTQ+ community in health care settings and schools, protections which have been systematically dismantled by the Trump administration. These fundamental protections are critical to reducing stigmas that have harmful mental and physical health consequences.

10. Given that overdoses and suicides are decreasing US life expectancy, evidence-based treatment options are critical, but treatment options are still limited. What role do you see research playing in improving mental health and addiction treatments?

Research must always be the backbone of innovations in mental health. I will continue to support increases to the National Institute of Mental Health (NIMH) budget and will reverse the cuts that the Trump administration has made.

11. Is there anything else you’d like to share with the mental health and addiction community?

I hope to help change the narrative around mental health and addiction in this country. This affects all of us. Mental health is core to overall health and well-being, and my hope is that our mental health and addiction plan will bring us toward a more comprehensive and integrated approach to mental health. In the wake of the recent mass shootings in El Paso and Dayton, it is also important that our nation’s response focus on the core issues that give rise to such violence: homegrown white nationalism and a lack of commonsense gun control policies. Unfortunately, some of the political and media responses have used these tragedies to further stigmatize those with mental illness, who are in fact more likely to be victims of gun violence.