If you want to talk about inequality in America, you should be talking about mental illness -- and the ability of people to get treatment for it.
On Thursday, the U.S. Centers for Disease Control and Prevention released a new study that demonstrates, in vivid terms, something that public health experts have known for a while: Mental health problems are far more common among the poor than the rich.
The basis for the study is five years of responses to the National Health Interview Survey, an in-person poll that the federal government has operated continuously since the late 1950s. Today’s version includes questions designed to measure the prevalence of “serious psychological distress,” a standard that public health experts use as a proxy for certain kinds of mental illness.
Infographic by Cameron Love
According to the new CDC paper, 8.7 percent of people with incomes below the poverty line, or $20,090 for a family of three, reported serious psychological distress from 2009 to 2013. For people with annual incomes at or above four times the poverty line -- that’s $80,360 for a family of three -- the figure was just 1.2 percent.
Researchers also discovered that about 30.4 percent of working-age adults with serious distress had no health insurance, compared with just 20.5 percent of working-age adults without serious distress.
The study, whose lead author is CDC epidemiologist Judith Weissman, does not address the issue of causality -- in other words, whether mental health problems lead to more economic hardship or whether economic hardship leads to more mental health problems. But most researchers believe the process works in both directions.
Studies have shown, for example, that infants and toddlers growing up in low-income communities are more likely to experience the kind of “toxic stress” (neglect, abuse, seeing violence in the home) that can hinder brain development and lead to mental illness in adulthood. Additional studies have suggested, though not conclusively, that adults who become unemployed are more likely to develop depression.
At the same time, somebody who had mental health problems might have a tougher time holding onto a job -- or, at least, a good job. And without employment, historically, it’s been tough to get health insurance or to have enough money to pay for timely detection and treatment of psychiatric problems.
For the people and families that deal with mental illness, the result can be a vicious, downward spiral that -- in the worst cases -- ends with some combination of medical and financial catastrophe.
A major goal of the Affordable Care Act, or Obamacare, was to address these problems -- partly by helping millions of additional people to get health insurance and partly by requiring insurance plans to provide more comprehensive coverage of mental health care. These regulations were an extension of bipartisan efforts, dating back to the 1980s and 1990s, to establish parity between mental and physical health care coverage.
The data in this latest CDC study isn't recent enough to capture most of the Affordable Care Act’s effects. But another study, focusing on a provision of the law that became effective back in 2010, found that young adults who obtained insurance were more likely to get mental health treatment. Studies of past government initiatives with similar characteristics, such as an expansion of Medicaid eligibility in Oregon, have provided yet more evidence that access to health insurance leads to better mental health.
Still, many people who obtained insurance under the Affordable Care Act struggle mightily to get mental health care -- either because they have trouble finding providers who accept insurance or because they face daunting out-of-pocket costs for every treatment session and prescription. That’s why organizations like the National Alliance on Mental Illness have called upon officials to find ways of further improving mental health coverage -- whether by providing people with more protection from high deductibles or strengthening the regulation of networks of mental health care providers.
Not everybody would favor such an approach. The Affordable Care Act’s conservative critics frequently call for scaling back the existing requirements on mental health insurance, because, they say, such mandates tend to drive up insurance premiums. They are probably right about that, although untreated mental illness can lead to future health problems, both mental and physical, that can be expensive to treat.
CORRECTION: An earlier version of this article mistakenly identified the NHIS as the National Health Insurance Survey. It is the National Health Interview Survey.