About Everything: The Surge in Mental Health Services

The Doctor is in: Treating America’s Mental Health Epidemic.


Editor's Note: In this complimentary edition of About Everything, Hedgeye Demography Sector Head Neil Howe discusses why "mental health services spending is riding a long-term attitudinal shift that has brought mental health issues out into the open." Howe explains why it's happening and the broader implications.


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Mental health care is booming. Since 2003, national spending on mental health services (MHS) has nearly doubled—and is expected to reach $229 billion in 2016. Its growth is far outpacing GDP. 


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Sure, the industry isn’t growing quite as fast as health care at large. But the fact that they’re in the same ballpark is impressive, considering that behavioral treatment, unlike somatic medicine, is still what it’s always been—low-tech therapy plus (mostly) vintage pharmaceuticals. In other words, MHS growth is driven almost entirely by volume, not service intensity.


Profit margins on all this volume expansion remain high. Acadia Healthcare, which boasts the largest network of inpatient and outpatient treatment centers, was recently named one of Kiplinger’s hottest stocks to own in 2016. Share prices of Universal Health Services (which specializes in MHS) have nearly tripled over the past three years. Hospital giant HCA Holdings cites its behavioral health business as one of its fastest-growing service lines. American Addiction Centers has been on a buying spree since it debuted on Wall Street with a market cap of $314 million in late 2014. 


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These companies are spending big on physical infrastructure. Community Healthcare System plunked down nearly $5 million to build onto its psychiatric unit. In Sonoma County, California, a sprawling $2.6 million, 14,066-square-foot mental health facility is in the works. The number of eating disorder facilities has more than tripled in the past decade.


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New laws and mandates. In 2008, Congress passed the 2008 Mental Health Parity and Addiction Equity Act, which required all private health insurance plans offering MHS to do so on the same basis (cost sharing, etc.) as other health benefits. In 2014, the ACA required all private insurers to offer MHS benefits.


The ACA also sets a minimum MHS standard for all state Medicaid plans, which is triggering a swift climb in Medicaid spending on both outpatient and inpatient care. Even as Medicaid is spending more on mental health, an exploding number of Disability Insurance beneficiaries with emotional problems are “retiring early” on Medicare. UHS generates a whopping 40 percent of its revenue from Medicaid and Medicare reimbursements.


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Growing incidence by cohort. Extensive research has shown that, throughout the postwar era, successive birth cohorts have exhibited depression symptoms at ever-earlier ages. Americans today moving past age 65 have more mental health problems than previous generations of elders did. 


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Generational change: Unhealthy Boomers. Boomers’ notoriously unhealthy lifestyle choices have burdened them with chronic diseases and disabilities which are often comorbid with emotional disorders. For example, Boomers are bringing their high rates of substance abuse (most recently, opioid addiction) with them into their 60s.


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Generational change: Care-Seeking Millennials. An average high school student today is twice as likely to see a professional for emotional problems as a student was in the early 1980s. College counselors are reporting rises in mental illness (from anxiety disorders to depression) among students.


Much of this increase comes from the fact that institution-trusting Millennials are simply much more inclined to seek care from a medical professional than rebellious Boomers or cynical Xers were in young adulthood.



New frontiers of behavioral health treatment could further accelerate industry growth. Although most policy makers agree that people suffering emotional disorders deserve care and supervision, much research shows that traditional treatment modalities may barely work better than a placebo. Now that may be changing. Thanks to advances in  neuroscience, caregivers may soon be using “biomarkers” found in blood tests, brain images, and saliva samples to identify and treat mentally ill patients—which could produce results in a matter of days.


Deinstitutionalization has created a ripe market for privatized mental health care. In the mid-1950s, more than 500,000 people with severe mental illness were institutionalized in state psychiatric wards. Despite six decades of population growth, that number is now under 100,000. The rest now in live in the community. General hospitals, inpatient facilities, and psychiatric clinics are left to pick up the slack. Firms like Acadia, HCA, and American Addiction Centers are jumping in to serve this need.


The demand for MHS is virtually unlimited. Or, to put it differently, the demand vastly exceeds the supply. Public policy deliberately constrains spending by making MHS unavailable to most Americans who cannot afford it through private insurance. Most U.S. counties don’t have a single psychologist, psychiatrist, or social worker. The controversial IMD exclusion further limits care by capping Medicaid funding for large state-funded mental health institutions (which have been gradually closing their doors).


Increasingly, Americans may feel that it’s cheaper to serve this demand than to ignore it. For every dollar spent on major depressive disorder in 2010, almost $7 was spent on the effects of untreated depression.


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The rising social cost of addiction alone is a growing concern. And then there’s the emotional toll of tragedies like Sandy Hook and Aurora, perpetrated by the mentally ill. As the public becomes increasingly aware of the link between mental illness and mass murders, legislators may become more willing to spend on evaluation and treatment up front. This of course would be great news to the MHS industry.



Accelerating MHS spending is riding a long-term attitudinal shift that has brought mental health issues out into the open:

  • Back in the early postwar era, the G.I. and Silent Generations who ran America carefully avoided any mention of emotional distress for fear of being locked away.
  • Boomers and Xers now go on Oprah to talk endlessly about their mental issues—and also about the social benefits of treating the untreated.
  • Millennials trust professionals to diagnose and treat the mental health problems that they suffer from.

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