A market for mental health insurance?
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Mental health is a subject often not spoken about voluntarily, except by professionals in the field. Mental health insurance is even further from the discussion. There is a shortage of service providers as well as services. Several barriers deter the progression of mental health services in low- to middle-income countries like India, including inadequate funding, concentration of services in urbanized centres, lack of integration with primary care services, and lack of experience and training among mental health professionals.
The new Mental Healthcare Act 2017 includes the following clause under the right to equality and non-discrimination: “21 (4) Every insurer shall make provision for medical insurance for treatment of mental illness on the same basis as is available for treatment of physical illness.”
The health insurance industry in India offers individual and family coverage, primarily for physical ailments. In general, coverage includes hospitalization or treatment at hospitals in the country. To indicate the magnitude of health coverage, in 2015-16 health insurance premium collections were Rs27,457 crore, indicating a growth rate of 21.30% compared to the preceding year, according to the Insurance Regulatory and Development Authority. With respect to mental health insurance, its multifaceted nature becomes evident based on anecdotal evidence from mental health professionals across the world.
For instance, the UK offers complete coverage for medical, surgical, psychological and psychiatric services alike through the National Health Service. Indonesia has public insurance (covering physical and mental illnesses) and private insurance (most of which do not cover mental illnesses). Nations differ widely with respect to the nature of coverage, as well as the extent of implementation of mental health insurance. Limits may be set on the total amount spent (on psychotherapy or psychopharmacological treatments), or the number of outpatient visits, or the number of hospitalizations and so on. India currently does not have any insurance coverage for mental health disorders.
Still, the nature of healthcare in India is evolving, with some insurance agencies offering coverage for Ayurveda, Yoga and Naturopathy, Unani, Siddha, Homoeopathy (Ayush) treatments. At the same time, psychiatric and psychological disorders appear on the exclusion lists of prominent agencies.
Is this because actuarial scientists haven’t been able to compute how premium rates for mental disorders can be determined? Or because of the stigma associated with mental health as a whole? Or because diagnostic classifications and manifestations of mental illness alter in different cultural contexts? There are many conjectures regarding the motivations underlying the exclusion of mental health insurance, including the problems faced by agencies in corroborating diagnoses with psychometric evaluations. Similarly, there are many reasons why disorders that affect a large proportion (13.7%, according to the National Institute of Mental Health and Neurosciences) of the population should be insured as well.
First, introducing mental health insurance may encourage mental health literacy among the population in a top-down approach. For instance, individuals who opt for health insurance or who receive it from their employers are assumed to have a fairly good understanding of the treatments involved for physical illnesses. Surgery, chemotherapy and the like are familiar terms of treatment. However, if individuals are uneducated about treatment counterparts in mental healthcare (for example, the types of psychotherapy, psychopharmacological medicines, etc.), they may not understand what mental health treatment entails, thereby perpetuating a cycle of ignorance and stigma.
Second, bringing mental health disorders at par with physical illnesses may “normalize” such diagnoses, reducing associated myths and stigma.
Third, access to licensed mental health professionals may increase via such coverage. Insuring psychiatric and psychological illnesses can increase the accountability of professionals, formalize treatment modalities, and decrease the likelihood of clients visiting pseudo-professionals for mental health concerns.
Fourth, acknowledging that some mental disorders have a biological basis helps determine the actuarial risk of such illnesses and educate relevant stakeholders.
The disparity between physical and mental healthcare is evident across several dimensions, like discrimination, stigmatization, health literacy, health infrastructure, and insurance. Specifically, we can aim to understand how the current mental health scenario in India can benefit from the introduction of mental health insurance. This in turn has policy implications for the National Mental Health Programme with respect to the dissemination of cost-effective mental health services.
Given the burden of mental health illnesses in India, collecting data at the time of the introduction of the Mental Healthcare Act and its provisions can guide the subsequent implementation of mental health insurance. The willingness to pay for mental health insurance will also allow evaluations of the potential outreach of such legislation. Addressing mental health concerns explicitly has the potential to facilitate de-stigmatization, improve mental health infrastructure and psycho-education, reduce costs to patients, and increase compliance with treatment.
Hansika Kapoor is a practising psychologist (clinical) and research author at the department of psychology, Monk Prayogshala, Mumbai.