Can premiums ever balance costs in mental health care?
Can premiums ever balance costs in mental health care?

By now we’ve seen enough.  Most people realize the need for effective mental health care for people struggling with serious mental health issues. But there’s a reason that people who are most likely to need the highest levels of care are least likely to get it: the simple economics of insurance.

An insurer’s profit is the difference between premiums (on one hand) and claims plus the cost of doing business (on the other). Mental health services are expensive and time intensive. Relapse is common. People who receive mental health care have lower-quality insurance or receive disability payments. Severe mental health concerns don’t often pair with a job that allows the ability to find out what works best and for how long.

So the math doesn’t add up: in the case of mental health, claims submitted can easily exceed premiums paid. That’s bad for the bottom line and you can bet that insurance company stockholders know it.  So what’s the answer? For insurance companies, the least bad answer is to offer the cheapest treatment that results in the biggest gains in the shortest amount of time. In most cases, that’s medication. But does the plug-a-pill approach really results in the best long-term results, for society, for the person taking that pill, or for the insurance company’s bottom line?

Consider this:

1. Symptom Reduction:  Costly

Don’t get me wrong: for a lot of people, SSRIs, antianxietants, and antipsychotics are exceptionally effective.  They reduce symptoms and make patients feel immediately better. I know that many things affect the brain; for example there are recent correlations between suicidal tendencies in women and a common parasite found in cat feces, and the brain processes serotonin differently as we age. Inflammation of the basal ganglia can really make a person act psychotic.  Psychiatric drugs can be like putting a bandaid on a broken leg.

The side effects can be crippling and sometimes fatal .  And they’re not cheap, either – while medications and their management may cost an insurer less than continuing talk therapy, you can bet that drug companies have stockholders too. So the question is, what’s the long-term cost? Does the lower monthly cost for a lifetime of meds  (that cause other problems) really outweigh the higher monthly cost of two years of actively helping people  learn to cope in different ways?

Insurance companies may prefer medication because it matches the medical model to which they are accustomed.  What if it costs too much, does too little, or creates a host of other health challenges that reduce the balance of effectiveness?  Reducing symptoms through  drugs makes it easier for everyone else.  By the way—the stats on who commits gun crimes are astonishingly low for people who are diagnosed with some form of mental disorder whether or not they are on medication: under 20%.   Who’s doing all that shooting?

2. Learning to Function Differently: Costly

In some ways, “mental illness” is an invention: it’s an invented set of labels applied to non-standard ways of living and thinking. Diagnoses are defined by people who have much to gain by placing people in these categories ,  The categories themselves are loose: there’s no equivalent of a strep test, bacteria culture or MRI for mental illness.

Does this mean that I believe mental illness isn’t real?  Not hardly.  I know people whose worlds are inside out and upside down. (And for some, I’m grateful for the medication that, when taken regularly, quells their inner torment.)

But the medical model doesn’t fit: something doesn’t need to be a “biological brain disorder” to be real – it may be a “learned way of being” that once helped the person deal with difficult experiences to which the brain has accommodated.  Here medications may mask the symptoms in ways that specifically disallow learning and practicing new ways of being.  In these cases of learned adaptive behavior, medication may keep people from getting well.  That’s not right.  And I don’t know anyone who has some form of mental disorder who wants to be “sick.”  The numbers tell us that in any group of four people, one has or will have a DSM diagnosis.. and the other three know someone who does.

3. The Double Bind: How to Resolve It

So what’s the answer for insurance companies?  Seriously?  I’m not sure there is existential congruence between health insurance and mental health care as it is currently practiced. No matter the strategy, as long as insurance pays anything for “mental disorders” from post-partum depression to acute psychosis, the “mentally ill” on insurers’ plans will always depend on the premiums of other members who are not so diagnosed.

If you’re one of the few who doesn’t take meds for ADD, depression, bipolar disorder, anxiety, stress  PTSD or trauma and if there’s no one in your family who does, you’re paying for someone else’s care.  Is it worth it?  Really, I’d love to hear your comments. What’s the least bad answer – for you, for people who receive care, for insurers, for society?