Economics and Behavioral Health.

• Author: Maclean, Johanna Catherine

Behavioral health disorders include serious mental illness and substance use disorders. These conditions are costly both to affected individuals and to society. Individuals with behavioral health disorders experience interpersonal problems, employment difficulties, reduced overall health, and increased risk of death. Behavioral health disorders can complicate general health treatment. These conditions are costly to society because they place demands on the criminal justice, social service, and health-care systems, and because they reduce labor market productivity. Behavioral health conditions cost the US economy more than $1 trillion each year. (1,2) The causes of these disorders are complex, and likely include both genetic and environmental factors.

Behavioral health disorders are relatively common. The most recent government data suggest that, in 2017, 4.2 percent of all US adults--11.2 million people--met diagnostic criteria for serious mental illness, and 7.2 percent--19.2 million people--had substance abuse disorders. Approximately 1 percent--3.1 million Americans--met criteria for both disorders. (3) A much larger share of the population engages in misuse of substances through activities such as binge drinking and recreational use of drugs, or experiences episodes of poor mental health such as mild depression or anxiety. The United States is in the midst of an unprecedented drug-use epidemic.

In 2017, 70,237 US residents are known to have died from a drug overdose. The drug-use epidemic has been largely attributable to opioids. There are 130 opioid-related overdose deaths each day, a rate that has increased more than sixfold since 1999. (4) The opioid epidemic is believed to have begun in the 1990s and 2000s through overprescription of opioids for the treatment of pain. It has evolved over time to involve heroin and synthetic opioids. (5) Abby Alpert, David Powell, and Rosalie Pacula, along with William Evans, Ethan Lieber, and Patrick Power, have documented that an unexpected, to consumers, reformulation of OxyContin in 2010, which limited the ability to abuse this then-most commonly used prescription opioid, led many users to transition to heroin and, more recently, to fentanyl and other synthetic opioids. (6 7) Synthetic opioids are less expensive to manufacture but are more potent than heroin and prescription opioids. Figure 1 documents trends in annual overdoses associated with any opioid, heroin, and synthetic opioids (other than methadone, which is a medication used to treat opioid use disorder). The sharp uptick in the later period is ascribed to fentanyl in particular. Federal, state, and local governments have adopted a range of policies to address the opioid epidemic: prescription drug monitoring programs, shutdowns of "pill mills," a crackdown on doctor-shopping, syringe exchanges, and funds to support treatment.

At the same time as the country is facing social costs from escalating drug misuse, government data suggest that suicide rates are also increasing. The overall rate and rates for men and women from 1999 through 2017 are shown in Figure 2.

While behavioral health disorders generally cannot be cured, there is substantial medical evidence that these disorders can be managed. This confluence of factors creates an important potential role for public policy, which can provide insurance coverage that is sufficiently generous, in terms of covered benefits, to allow appropriate treatment. In a series of studies, my colleagues and I explore how insurance expansions can...