The Substance Abuse and Mental Health Services Administration (SAMHSA) estimated that 58% of the adult population has a medical condition and that 25% of the adult population has a mental health condition. But at least as important is the rate of comorbidity that they estimate: 29% pf those with medical conditions have mental health conditions, and 68% of those with mental health conditions have medical conditions. Indeed, they find, those who have been diagnosed with asthma were 2.3 times more likely than others to screen positive for depression, and those with cardiovascular disease were 1.43 times more likely to have an anxiety disorder.
They estimate further that not only is there substantial overlap between these patient populations, but one may be a risk factor for the other. While 5% of the population without chronic medical conditions experiences major depression, the rate increases to 8% among those with one medical condition, 10% among those with two conditions, and 12% among those with three or more conditions. It is worth emphasizing that this is a nontrivial subset of the population – indeed, approximately 31.5% of American adults (and 49% of those ages 45-64) live with multiple chronic conditions, and 71% of American healthcare spending goes toward those individuals. These rates of multiple chronic conditions is higher for women than for men, with women also more likely to experience depression.
That chronic illness (or chronic pain) would be deemed a risk factor for depression is hardly surprising. Not feeling physically well can make it difficult to be in a good frame of mind. Moreover, chronic illnesses may be of a sort that can be treated but not cured, thus potentially causing changes of lifestyle and perhaps a sense of hopelessness about improvement. Moreover, medical bills and associated stressors (more medical tests, appointments, coordination of care among physicians) can produce financial strain and in turn anxiety and/or depression. That mental health conditions could contribute to worse physical health is also unsurprising considering the potentially worsened habits with respect to diet, sleep, and exercise, and may be less vigilant in treating chronic physical conditions (e.g., may become lax about medication management). The mental and the physical are inherently interactive.
The interactive nature of the two should be all the more reason to better integrated system of treatment than the United States currently offers. The problem is that it is much easer to obtain insurance coverage for medical than for mental health conditions, with only 55% of psychiatrists accepting insurance, compared with 93% of other medical providers accepting insurance and 86% accepting Medicare. What’s more, those who do accept insurance may accept a limited number of insurance patients or may have schedules that are full given the high demand and limited supply. This creates a system in which obtaining psychiatric treatment can in some cases become a luxury, despite the fact that those who are lower income are more likely to report depression. Indeed, 31% of those in poverty say that they have been diagnosed with depression at some point, compared with a rate of 15.8% among those who are not impoverished. Such individuals will be unable to go out-of-network as is often required of those seeking mental health treatment, and may even be unable to accord the various medical treatments that may be required for their chronic physical conditions. Failure to address one set of conditions can exacerbate or at least leave untended the other concerns.
And getting an in-network provider is just the first step. Services also need to be covered by the insurance company, and despite Congress’s 2008 passage of the Mental Health Parity and Addiction Equity Act, requiring that treatment coverage be equal for physical and mental health, the legislation remains poorly enforced, with insurance denials of 14% for physical health and 29% for mental health and insurance company challenges of “medical necessity,” and 25% of health plans were found inconsistent with the legislation.
Psychiatrists and other medical professionals are aware of the problems in treatment that pervade our healthcare system. Absent good medical care, one risks the exacerbation of both physical conditions and risk factors for mood and anxiety disorders. Absent good mental health care, one makes oneself more vulnerable to poorly managed physical health, regardless of preexisting conditions.
Yet for a private practice psychiatrist to take insurance is far from a costless enterprise, requiring the setting of a rate that insurance companies accept, marked paperwork of determining fees, collecting copayments while submitting for reimbursement and waiting for those fees to be processed, and challenging any insurance claims denials. This amount of paperwork can require the hiring of a secretary, which is an additional financial burden requiring even more profit. Given the needs to manage this paperwork, it comes as little surprise that the practitioners least likely to accept insurance are those operating in solo practices. Further, reimbursement rates for psychotherapy are low, thus disincentivizing in-network providers from doing anything other than brief medication appointments in order to stay afloat. This is particularly unfortunate given the reality that combining medication management and psychotherapy is the best treatment for depression compared with either treatment alone. Indeed, among those depressed patients receiving both medication and psychotherapy, 72% in a 2004 study achieved symptom remission compared with 57% of those receiving only medication management.
It is difficult to begrudge psychiatrists from responding to financial incentives. The average medical school debt is $180,723, in addition to which physician salaries overall are actually declining. Getting out of debt is a more than reasonable expectation, as is a monetary reward for the hard work of medicine. The problem, rather, is in the incentives that insurance companies create in structuring lower reimbursement rates for psychotherapy augmenting pharmacological treatments.
Raising reimbursement rates to physicians is not something that is at all profitable to insurance companies, which have already in many cases reported losses in recent years in the aftermath of the Affordable Care Act, with insurers losing money in 41 states in 2014. Insurance companies are for-profit and thus by definition are not in the business of providing charity or even operating at cost, but rather employ strategies to reap financial gains. The problem, though, is that public health and economics don’t always have incentives that are aligned – in fact, short term incentives are often not. Band-aid solutions are easier and may be cheaper in the short-term (though may yield greater long-term costs due to ineffective treatments). Effective public health interventions are expensive and require both financial and policy commitments to change irrespective of insurer profits.
The reality is that effective mental health treatment is economically beneficial in the long run, albeit not necessarily the short term. Early interventions can obviate the need for more expensive medications and hospitalization. Major depression is the leading cause of disability in the United States among 15-44 year-olds, thus yielding lower economic productivity and the drawing on government resources in the form of disability and Medicaid. And as discussed above, it can potentially reduce the exacerbation of other physical conditions that are costly to treat. Reducing the future need for expensive treatment might best be averted through effective treatment in the present, ideally proactively, though this is not a model that is particularly consistent with the profit motives of the current American healthcare system.
The other reality is that politics is incremental. Sanders’ Medicare for All health plan is by far the most leftward turn that has been proposed at a national level, particularly given the vigilance with which members of the Republican Party have fought the Affordable Care Act, with the 2016 GOP platform declaring a commitment to the ACA’s repeal. Given the frequency of divided government and the extent of polarization on this subject, expanding Medicare to all Americans was not a policy that would have garnered nearly adequate support even with the fact that diseases from diabetes to depression affect Democrats and Republicans alike. For all its politicization in Washington DC, health is (or should be) fundamentally a human and not a political issue. Clinton’s plan expands on the progress of the ACA within the confines of the political reality in which she operates – that is, maintaining the existing healthcare apparatus but working to curb out-of-pocket costs and prescription drug prices, and incentivizing the rest of the United States to adopt Medicaid expansions to help low-income Americans.
This will do much to address the fact that 31 million Americans have underinsurance, with many facing high deductibles and other out-of-pocket costs. However, it will not address the reality that insurers’ profit motives are not conducive to supporting some key evidence-based medicine. Having government insurance plans provide better mental health coverage will be an essential move, and the importance of emotional wellbeing thankfully has been addressed squarely by the Obama Administration in general and the Surgeon General in particular. So what are some other options?
Pushing insurance companies to better streamline claims processing to reduce the paperwork burdens of physicians’ insurance participation might at least make less daunting the prospect of operating a solo or small practice with insurance clients given paperwork burdens that are currently pervasive. Finding ways to provide government financial incentives (potentially tax breaks) to companies to make healthcare more accessible – both in the form of physician and patient reimbursements – would be an additional option to broadening access to care. This will be particularly valuable in the case of psychiatrists' reimbursement for psychotherapy so as to better facilitate evidence-based mental health care. Increasing forgiveness of medical school loans based on the share of low- and middle-income as opposed to private-pay patients will be another way to reduce the extent to which physicians’ financial needs drive the type of care that they are capable of providing their patients. Such an approach would be in line with current plans that incentivize working in underserved areas, and could make it more feasible to take on patients relying on plans that may or may not reimburse doctors at as high rates (and certainly providing less lucrative work than private-pay) but whose physical and mental health struggles must be treated.
When you enter an emergency room, you see signs that you are entitled to receive medical care regardless of insurance status or ability to pay. Doctors provide the medical care that they know to be needed, whether the patient is a Democrat or Republican, a criminal or the victim of a crime, poorly or highly-educated. In a world in which politics too often trumps policy, our healthcare system needs to do a better job of facilitating medical decisions that deliver the best quality care to the broadest reach of the population.