ROBERT SIEGEL, HOST:
Many people who get mental health care in this country aren't the ones who need it most. That was the conclusion of a study published nearly 20 years ago in The New England Journal of Medicine, but Keith Humphreys still cites it a lot. He's a psychiatry professor at Stanford, and he's advised the government on mental health policy. He says in the U.S., a lot of the people using mental health care are the people who can afford to pay for it. April Dembosky of member station KQED in San Francisco talked to Humphreys about how that situation came about.
APRIL DEMBOSKY, BYLINE: There's something that really bothers Humphreys. Training a new psychiatrist takes years - years of medical school and residency.
KEITH HUMPHREYS: And then what they do is charge $400 an hour in cash to take care of the worried well.
DEMBOSKY: Worried well - as in a tech employee from Silicon Valley who's stressed at work or has existential angst, but doesn't have a mental illness.
HUMPHREYS: You know, I just feel like a minute I spent training that person is a minute of my life I wasted. That very well-trained person should be taking care of very, very troubled people. And when they don't, everyone who needs that care, in a sense, loses out.
DEMBOSKY: Humphreys says this trend of mental health clinicians decamping to the cash market started 70 years ago.
HUMPHREYS: Age of mental health in the United States starts right after the war.
DEMBOSKY: The Second World War. In 1946, the majority of veterans who were being cared for by the VA had mental health problems.
HUMPHREYS: And there weren't anywhere near enough mental health providers to take care of that population.
HUMPHREYS: So the VA partnered with several medical schools, including Stanford, where Humphreys teaches, to train mental health professionals.
HUMPHREYS: Hundreds and hundreds and hundreds a year.
DEMBOSKY: And the VA became the largest employer of psychologists. At the same time, Humphreys says, affluence in America was soaring. Interest in individualism and self-exploration was also soaring.
HUMPHREYS: It starts to become sort of a status symbol to have a psychoanalyst.
DEMBOSKY: A lot of the psychologists who were trained to work in the public sector saw a better financial opportunity in private practice, where they could charge wealthy people much higher rates. This phenomenon is unique to the U.S.
HUMPHREYS: In a nationalized health economy, that wouldn't be possible because there'd be a central tap of the money controlled by the government.
DEMBOSKY: Instead, in the U.S., people historically got their insurance through work. Employers set the benefits, so coverage was fragmented and inconsistent. Mental health was often left out, and the cash market sprang up in its place.
HUMPHREYS: If it's a market where pretty much you have to pay for yourself, the rich are always going to win.
DEMBOSKY: In affluent places like Silicon Valley, this creates a culture of mental health haves and have-nots. Therapists don't need to take insurance to keep their schedules full, and that makes it harder and harder for people of lower income to find help.
HUMPHREYS: Maybe they're suicidal, or maybe they're, you know, horribly addicted to OxyContin. Or their child is showing signs of bipolar disorder, and they cannot get somebody to take their insurance. It's unjust.
DEMBOSKY: Several recent health laws have aimed to balance the scales by requiring insurers to offer mental health coverage on par with other medical coverage. But so far, therapists haven't been flocking to sign on with insurance companies. And Humphreys says given the nature of therapy, the cash market is here to stay.
HUMPHREYS: Accessing mental health care is often pleasurable and enjoyable, and accessing lots of other health care isn't. Who goes to the dentist for fun? You know, nobody.
DEMBOSKY: For NPR News, I'm April Dembosky in San Francisco.
SIEGEL: That story is part of a reporting partnership of NPR, KQED and Kaiser Health News.
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