Last December, the now-infamous Newtown, Connecticut mass shootings that claimed 28 lives — 20 of which were young schoolchildren — touched off another chapter in this country’s recurring and fierce national debate about gun control, a debate that tends to resurrect itself whenever there is an incident of mass violence shocking enough to stir both popular and political will into revisiting the topic. But Newtown also kick-started a national discussion on improving mental health care, since no matter where one stands on the issue of gun control, Americans seemed fairly unanimous on the points that 1) mass killers often suffer from some form of mental illness, 2) preventive treatment of such mental illness could save lives and 3) there needs to be a better way to get mentally ill people the help they need.

National Underwriter began a four-part series to address this challenge regarding mental health care, with the second part scheduled to run online in late April and to appear in print in early May. Fate, it seems, has a strange sense of timing, for shortly before the publication of this story, two brothers of Chechen descent — Tamerlan and Dzhokhar Tsarnaev — detonated a pair of bombs in the spectator section near the finish line of the Boston Marathon, killing three (including an eight-year-old boy) and wounding more than 200 others, many severely. Over the course of the week that followed, the Tsarnaev brothers led Boston-area police as well as state and federal law enforcement on a chase that would leave Tamerlan and a Massachusetts Institute of Technology police officer dead and Dzhokar shot in the throat and severely wounded, but in custody. At the time of this writing, the Tsarnaev’s motives are unclear, but given the brother’s failure to flee the city immediately after they bombed the marathon (Dzhokar even went back to his college and attended a party while Tamerlan checked up on his car in the shop), and their overall fumbled attempt to escape once authorities did close in suggests not that they were part of a larger terrorist plot but were instead merely a pair alienated, homicidal figures who attacked one of the world’s most famous sporting events for reasons that probably make no sense to anyone but themselves.

In that, the issue of mental health care has lost none of its potency or timeliness, even though, statistically speaking, the mentally ill are far more likely to hurt themselves rather than another person. Mere days before the Boston bombing, a gun control bill aimed at shoring up background checks and restricting high-capacity magazines failed to make it to a vote in the Senate, dashing hopes among Congressional Democrats and the Obama administration that they could make good on post-Newtown vows to keep the heaviest hardware out of the most inappropriate hands. (This would have done nothing to stop the Tsarnaevs, however, as their weapons of choice were improvised explosive devices made from pressure cookers.)

For mental health advocates, the Senate bill contained a package of provisions that had strong bipartisan support and would have funded the construction of community mental health care centers, provided training for teachers to spot students in crisis, and expanded Medicaid dollars available for mental health care. While mental health advocates found the connection between mental health and gun violence in general to be distasteful and stigmatizing, the measures were an expedient way to overhaul mental health care in general. Now it is just another footnote in the annals of failed legislation, and once again, if any forward motion is to be made in this arena, it falls to those who have been best suited for it all along: the private health insurance industry.

But how much more can the insurance industry do? How much of the overall cost burden of mental health care is the industry already carrying, and how much more can it be expected to bear before something gives way?

Breaking down the numbers

According to the National Alliance on Mental Illness, one in four adult Americans — nearly 58 million — experience a mental health disorder in any given year. One in 17 has a serious mental illness, such as bipolar disorder, depression or schizophrenia. One in 10 American children has a serious mental or emotional disorder. Fewer than one-third of these adults — and only one half of the children — with a diagnosable mental disorder actually receive mental health services in a given year. Individuals living with serious mental illness face a markedly higher risk of other chronic health conditions; adults living with serious mental illness have a lifespan 25 years shorter than their healthy counterparts.

Despite the large number of mentally ill who do not receive treatment, the United States manages to spend an enormous amount on mental health care services every year. In 2011, the Substance Abuse and Mental Health Services Administration (SAMSHA) released data that in 2005, the most recent year for which data was available, the United States had spent about $113 billion on mental health care services (this does not include the cost substance abuse treatment, which accounts for another $22 billion in annual spending). To give a sense of how much money that is, the Marshall Plan to reconstruct post-WWII Europe, would have run $115 billion in today’s dollars. Just two years of mental health care spending at this level would more than cover the projected $230 billion price tag for a manned mission to Mars. And yet, this all pales before the $1.85 trillion the U.S. spent on all health care in 2005.

Let’s take a look at how this all breaks down. The numbers will not quite add up because of rounding, but they will give a fairly accurate picture of where the mental health care dollars are going.

Of the $113 billion spent in 2005 — a figure almost certainly smaller than what was spent in 2012 — $16.7 billion went to general hospitals. $13.4 billion went to specialty hospitals (mental health in-patient facilities, mainly). $16.3 billion went to physicians, while $5.8 billion went to other professionals, such as social workers. $6.8 billion went to freestanding nursing homes, and just over $1 billion went to freestanding home health services. $14.3 billion went to specialty mental health centers. $8.4 billion went to insurance administration — the part of the equation that includes, among other things, how much profit insurers take out of health insurance transactions. But by far, the biggest slice of the pie went to retail prescription drugs, which came in at $30 billion, or 26.5 percent of all mental health care spending for the year.

What is incredible about drug spending for mental health care is how much it has grown in the last 25 years. In 1986, retail drug spending was just $2.3 billion out of a total of $31.8 billion spent on mental health care, or about 7.4 percent of the whole. By 2005, retail drug spending had increased nearly 12 times. In comparison, total mental health spending had only increased by 3.5 times.

What happened? In a word, antidepressants. By the late 1980s, the market was long overdue for an improved generation of antidepressant medication that didn’t feature such harsh side effects (such as weight gain, sluggishness and the occasional fatal overdose). The introduction of selective serotonin reuptake inhibitors (SSRIs) such as Prozac in 1987, Zoloft in 1991 and Paxil in 1992 revolutionized drug therapy for mental health disorders. Collectively, these drugs were as successful as their predecessors, but had fewer side effects, and were much easier to prescribe without risking an accidental overdose. By 1990, there were 650,000 Prozac prescriptions being written annually, and over the next decade, antidepressant use across the country quadrupled. For many years, retail drug spending grew faster than any other portion of overall mental health care spending, but by the mid-2000s, this leveled off as the big second-generation antidepressants’ patents expired and cheaper generics hit the market. But by then, there was no going back: Drug spending was a major and permanent cost of treating mental illness.

By 2005, of the $113 billion spent on mental health care, SAMSHA reports that $30.4 billion was picked up by private insurance. $30.4 billion is no small number — were that to be a catastrophe loss suffered by the property/casualty insurance market, it would be the most costly on record, superseding the $25 billion in insured losses caused by Superstorm Sandy last year, as well as the $24.6 billion in insured losses caused by the 9/11 terror attacks.

And yet, under scrutiny, the private insurance sector’s portion of the mental health tab begins to diminish, comparatively. In 2005, private health insurance spending — all $690 billion of it — accounted for a little more than 37 percent of all health spending for the year. (The rest of the bill is mostly picked up by different government programs, such as Medicaid.) In that same year, the $30.4 billion spent by private insurers on mental health accounted for only 26.9 percent of the total mental health care bill. Put another way, of all of the private health insurance spending in 2005, only 4.4 percent of it was for mental health care. Even though these figures are sure to rise in the post-Affordable Care Act era, however one looks at health care spending, one thing becomes clear: mental health care is not breaking the bank.

Still coming up short

The Agency for Healthcare Research and Quality (AHRQ) maintains detailed health care cost comparison figures, and according to its current data, the number of Americans receiving mental health care treatment grew from 19.3 million in 1996 to 36.2 million in 2006. Of those, 4.6 million were children 17 years old or younger. The average mental health care cost per person actually dropped from $1,825 per person in 1996 to $1,591 per person in 2006 largely because by 2006, generic versions of the most popular antidepressants had entered the market. Average cost per child was a bit higher than the average, at $1,931 per person.

For adults receiving mental health care, the AHRQ reports that retail drug prescriptions were the primary method of treatment for 56.2 percent of them. Outpatient services, such as counseling and therapy, were the primary method of treatment for 40.5 percent of adults. Inpatient services were the primary method for just 7.5 percent.

In comparison, in 2006, 19.7 million Americans received treatment for heart disease, at an average cost of $3,964 per person. 11.1 million Americans received cancer treatment, at $5,167 per person. 34.9 million Americans received traumatic injury care (mainly from traffic accidents), at $1,953 per person. Cardiopulmonary obstructive disorder and asthma affected 48.5 million Americans, more than any other among the top five most costly diseases, but at the lowest average cost, at $1,059 per person. In such a crowd, mental health care comes in somewhere in the middle, with far more people suffering mental illness than, say, heart disease, but at a much lower average cost that is typically driven by pharmaceutical treatments lasting from six to 12 months on average.

According to medical journal Health Affairs, the AHRQ data is not as comprehensive as SAMSHA data, omitting institutionalized persons and under-reporting high-cost cases, emergency department visits and physician office visits. So the true average cost per person for mental health care treatment is likely to be higher than what the AHRW has reported. But compared to the much higher overall treatment cost for heart disease and cancer, mental illness, despite its large and hazy numbers, appears to be a fairly treatable condition, costwise.

All the more remarkable, then, when one considers further SAMSHA data stating that in 2011, 45.6 million Americans — nearly one in five adults — suffered from some form of adult mental illness, but of those only four out of every 10 actually sought treatment. When asked why they did not seek treatment, fully half said they could not afford the cost of services. On top of that, another 15 percent said that their insurance did not cover mental health services, or it did not cover enough treatment, despite the implementation of the Mental Health Parity and Addiction Equity Act of 2008, which required insurers to provide equal levels of coverage for mental illness as for other forms of disease.

Separate SAMSHA figures show that some 66 percent of outpatient mental health services from 2005 through 2009 cost less than $500. Nearly 31 percent cost between $500 to $5,000. Only 2.3 percent cost more than $5,000. Likewise, those same figures show that nearly 70 percent of inpatient services from 2005 through 2009 cost less than $2,000. Twenty-one percent cost from $2,000 to $10,000. Just under 10 percent cost more than $10,000. These expenditures are not trivial in real terms, but they do not blow away the average cost of treatment for cancer, heart disease or traumatic injury either, and one has a hard time imagining only 40 percent of car crash victims or cancer victims seeking treatment for their condition. Despite the passage of mental health parity and the Patient Protection and Affordable Care Act (PPACA), the mentally ill remain a largely untreated population, with large numbers of them falling through the safety net private insurance is meant to provide. In Part III of this series, we will examine the pricing and structure of the mental health component of private health insurance plans across the country to see just how much the industry has embraced its role as provider of first resort for mental health care.

See part 1 in the series, The darkness within