Amidst the current speculation about—and defense of—Donald Trump’s mental status, his physical today is well timed. Though Trump apparently has no plans to allow his doctor to assess his mental health, experts encourage primary care providers to screen all adults for and treat depression, anxiety, and other conditions that can be managed in a primary care setting. Encountering a patient who is facing extreme stress, holding on to intense emotions, feeling disconnected from former hobbies, and perhaps performing badly at work, many primary care doctors would recommend psychotherapy.
For most patients, such a recommendation presents a conundrum: who should the patient see, and who will pay for it? Despite mental health parity laws that should make access to mental health and other medical care equivalent, only 55 percent of psychiatrists accept insurance. Finding a therapist who accepts insurance may feel like browsing the fully covered eye glass frame selection: you can find some perfectly good ones, but there won’t be a huge selection.
For many people in search of psychotherapy, this is where shopping begins.
Shopping for any health care service is supposed to be impossible. The principle described by economist Kenneth Arrow in 1963 that health care is not—and cannot be—treated as a commodity still dominates prevailing health care wisdom. Yet consumers pay 10 percent—or nearly $20 billion—of mental health care bills out of pocket.
My own research on consumer behavior in health care purchasing shows that shopping is precisely what people do when they need therapy. A 40-something writer based in Los Angeles explained: “I basically chose my psychiatrist off the Internet for two reasons. One, he was covered in my [insurance] network, and two, he was in walking distance of my apartment.” Now he likens visiting his psychiatrist for medication checks to getting an oil change.
Others describe mental health care in more intensive terms. “It’s such an intimate relationship,” a freelance movie-maker based in New York City told me. “It’s someone you see once a week.”
With the average out-of-pocket spending on mental health care nearly $1,500 per year even for people with employer-based health insurance, therapy-seekers must assess value, quality, and the priority of the service. They must also determine what they are willing to pay, creating challenging trade-offs. “Right now, since I’m part time, I’ve decided to do my gym instead of regular therapy, which is probably a bad choice,” a high school teacher returning from maternity leave with her second child shared with me. “But I can’t afford both.” She is not alone. Cost prevented one fifth of Americans who need mental health care from getting treatment.
For others, it’s a no brainer. “I pay out of pocket and will continue as long as this woman is alive,” an architecture professor said of her therapist.
In some areas, paying for therapy is a cultural norm. “I feel like you live in New York, probably everyone goes to therapy,” a filmmaker told me. “You’re kind of an oddball if you don’t.”
Entrepreneurs and investors see therapy’s market potential. MIT-incubated Sophia matches patients with therapists like a dating site, while sites like Talkspace offer therapy online. Venture capital investment deals in mental health start-ups were on pace for a record in 2017, and they poured more than $250 million into nearly 50 companies since 2016. “Mental health is definitely an area of focus right now,” Caleb Winder, Managing Director of Excel Venture Management told me, based on the business opportunities to make mental health care more accessible to millions who need it.
Whether Donald Trump’s doctor will recommend mental health services or not, there is no doubt that Donald Trump could afford a great therapist if he wanted one. As the poster-child of conspicuous consumption, Trump might be more open to mental health care if he viewed it as many Americans experience it: a luxury.
Deborah Gordon is a Senior Fellow at the Mossavar-Rahmani Center for Business and Government at the Harvard Kennedy School. Follow her on Twitter @gordondeb.