Business and health groups can find ways to constructively interact. Former Surgeon General Jerome Adams tells a story about talking to some mayors who wanted to build sidewalks in their communities. His first thought was wow, they wanted to encourage walking to fight diabetes. Then he learned that they were actually trying to boost property values, and get more potential customers strolling into stores. And then he realized that it didn’t matter, the sidewalks would still fight diabetes — and create a way for business and health groups to join forces. Different goals. Shared gains.
“It’s not just a health care conversation. It’s an economic conversation, and health care is part of that conversation,” said Pennsylvania Insurance Commissioner Jessica Altman. “What part of this is the health care system’s responsibility to solve, and which is all of government’s responsibility?”
The pandemic, with its stark racial, ethnic and economic disparities, brought all that home. It turned social determinants from a talking point to an agenda item, entwined with, though not identical to, the national reckoning over race.
Every sector of society and the economy has been hit by the pandemic — and every one can be rebuilt with health and equity in mind. “We don’t just go back to where we were, because we weren’t in a great place,” said Cara James, who ran the Office on Minority Health at the Centers for Medicare and Medicaid Services during both the Obama and Trump administrations and now leads the Grantmakers in Health nonprofit. Equity has to be built in, she said. Not a P.S., but an “S.O.P.” — standard operating procedure.
Prepare now for a coming mental health tsunami.
Mental and behavioral health were daunting challenges well before the coronavirus plunged us into a year and counting of isolation, anxiety, economic hardship, disrupted relationships and grief. As we emerge, mental health will become an outright emergency; anxiety and depression are already elevated, and research has found that suicides often surge in the wake of disasters.
States should stand up hotlines and emergency services, as they work to expand mental health capacity longer term, including mental health community clinics, and a more robust behavioral health work force, including peer support and community mental health workers when appropriate.
“During the pandemic, everyone is triaging. Coming out of this, dealing with mental health will rise to near the top,” said Elinore McCance-Katz, who ran the Department of Health and Human Services’ mental health agency in the Trump administration, noting that not everyone will bounce back when the pandemic eases. “We can’t presume that when someone says, ‘It’s over,’ that everyone gets better.”
The federal government and the states should also expect to confront a rebounding opioid crisis, despite some hard-won pre-pandemic gains. “That is going to be a real driver of mortality — that and all the other deaths of despair,” said DeSalvo.
Still, the larger problem is that even before the pandemic, our health care system didn’t have adequate capacity. There aren’t enough mental health care providers, particularly in underserved areas, and many don’t accept the relatively low fees offered by insurers. Any “build it and they will come” state approach to growing the workforce will take time, so it should begin ASAP. States can also make sure their public employee health plans offer adequate psychiatric and counseling options, and create incentives like student loan forgiveness to encourage mental health professionals to go into underserved communities.
Christina Mullins, who runs West Virginia’s behavioral health, suggests that states need to improve their crisis services, including mobile units that can connect people to ongoing care. Congress can help by making permanent the emergency authorization allowing providers to be reimbursed for telemedicine — including covering telephone counseling and consults, not just audiovisual ones, for people who don’t have computers or who live in rural areas without broadband.
One of the biggest salves for mental health is to open schools as soon as safely possible for a whole long list of reasons, including that basic need of just letting kids have what they call “IRL” — for “in real life” — friendships and in-person contact with watchful adults who aren’t their parents (although the Biden administration may find that it’s easier said than done). McKance-Katz also wants mental health and behavioral clinics opened for in-person care — safely, with masks, distancing and fewer people gathering at any one time.
The bottom line is that it’s really hard for people to recover their mental health when they are facing all sorts of other real-life stresses. Recent data from the CDC upholds that assessment — and it’s worse for minorities. People with severe mental illnesses or who are in crisis need to be connected with social services, to get help with child care, housing and jobs.
None of those changes are easy, and all of them require money, focus and persistence from state officials and federal partners. But people working on improving public health have come to appreciate a central challenge that affects all of them: Trust in public health agencies and expertise has been damaged to the point that it is causing real harm.
Rebuilding trust is a theme new CDC director Walensky has emphasized in just about every public utterance since her appointment. She has pledged to lead with “facts, science and integrity,” even when the news is more bleak than what people or politicians want to hear.
Yet the erosion of trust predates Covid-19 and Donald Trump, although the former president’s assaults on science and depiction of public health as the enemy of economic recovery deepened it. Right now, the lack of confidence in vaccines — the only way out of the pandemic — is where addressing the corrosion is most urgent.
But vaccination may also be a second chance. If states and their federal partners use vaccination to show how governments really can keep people healthy, it could lay the foundation for rebuilding the national public health system we need to keep Americans healthier long-term.
“These are trust-building opportunities, and they should not end when the vaccination level is high enough,” said James, the former CMS minority health director. “There is work to be done. … Address this crisis to tackle other issues.”
Of course, it’s not only health care that has been stained by mistrust, she noted — it’s basically every sector of civil society. But conquering Covid, rebuilding public health, fairly and equitably, is a good way to start.