By Jen Elwood, Valerie Hamilton, and Jill Wilson
Inside Out 2 was the hottest movie of the summer. As of this writing, the film was the eighth-highest grossing movie of all time and the highest-grossing animated film ever.[1] Kyle Smith, a film critic for The Wall Street Journal, described Inside Out 2 as “[a] pointedly funny and observant parable of teen angst that has a lot to say about the state of youth today.”[2]
For those of you who haven’t seen the movie, it focuses on Riley, a teenager trying out for the high school hockey team. Like the first Inside Out film (2015), the movie mostly takes place inside Riley’s mind, with the emotions Joy, Sadness, Fear, Disgust, and Anger continuing their residence. However, one night, a literal wrecking ball appears in Riley’s brain to create adequate space for new emotions brought on by impending puberty. With this big life change, we meet: Anxiety, Embarrassment, Envy, Ennui, and (very briefly) Nostalgia. In this ensemble cast, the star of the show is Anxiety, who is intensely driven to help Riley get a coveted spot on the hockey team.
While the idea of returning to your teenage mind might send you running for cover, this movie is full of truthful human moments that strike a universal chord—not just the standard entertaining puns. The absolute best part about this movie is not mentioned in any reviews: Anxiety, the new headlining emotion, is an actuary! And for us actuaries watching the movie, it provides some insight into the importance of our profession, as well as some reminders of how we can best serve our clients.
As the new emotions arrive on the scene, the existing emotions wonder what purpose the new emotions serve. Poignantly, Joy asks why Riley needs Anxiety when she already has Fear to protect her. Anxiety aptly responds that while Fear protects Riley from the things she can see, “My job is to protect her from the scary stuff she can’t see. I plan for the future.” It doesn’t get much more actuarial than that. While actuaries can and do quantify known risks and provide mitigation strategies, our core strength is seeing the future risks that others may miss, just like Anxiety. It’s the one thing that brings all our disciplines together, our common denominator as a profession across the globe.
Picture this scene: Anxiety using a computer to connect with a collection of analysts in cubicles made of playing cards, presumably working diligently in the back of Riley’s brain. Anxiety asks them to run the data and help her generate “scenarios” for what could happen. Anxiety then uses those scenarios at the control desk to steer Riley’s actions, similar to an actuary advising senior leadership or a client on the potential risks created by a changing environment. For example, early on, Riley learns that her two best friends will not be attending the same school she will be attending in the upcoming school year. Anxiety takes in this new and emerging information, analyzes how it will change her current outlook, and projects a likely scenario where Riley will be without friends—with the best risk-mitigation scenario being for Riley to make new friends quickly. Anxiety decides the best way to avoid the negative scenario of being lonely is for Riley to ditch her current friends during hockey camp and make new ones.
This decision has some early repercussions. Riley’s friends are hurt that she isn’t hanging out with them anymore. And worse, Riley chooses a strategy to try to impress the friends she is courting by disparaging her current friends—mocking their mutual favorite band. Her cost/benefit analysis is relatable, albeit unfortunate in this case. Her chosen course of action could be considered a short-term loss for a potential long-term gain. Similarly, in the course of their work, a pricing actuary may decide to increase premium rates for a particular product line in order to avoid projected losses. In the short term, there is a risk the product could lose customers—particularly if the market doesn’t immediately follow. However, with a long-term view, the product will be priced fairly and—deploying a marketing strategy that doesn’t disparage former customers—well positioned in the future.
In a later scene, Joy interrupts the analysts and encourages them not just to focus on negative scenarios as Anxiety instructed. Anxiety is risking overestimating the threats that Riley faces and Joy, in an effort to rebalance Riley’s perspective, pleads with the analysts to consider positive scenarios. This point of conflict between Joy and Anxiety is reminiscent of executive leadership conversations across industries. Actuaries often are charged with exploring the worst-case scenarios and mitigating those potential risks; but actuaries are wise to consider multiple realistic scenarios as well, both positive and negative, to help inform executive leadership or client decisions. Only then can actuaries balance their decision-making and take risks thoughtfully across the wide breadth of possibilities.
Anxiety is trying to make the best possible decisions for Riley and keep her safe. Unfortunately, she makes a few critical errors along the way. One of her first missteps is abandoning the decision-making framework that has gotten her to this point. While growing up, Riley developed a set of core beliefs that guided her decision-making. The beliefs were formed deep inside her mind based on a collection of memories and life moments and are integral to how Riley perceives herself and the world around her.
Her core beliefs are like the ethics and professionalism standards that all actuaries follow. The core beliefs of our profession—our high professional standards—require a combination of competency, integrity, objectivity, and a commitment to serve the public, as described by the American Academy of Actuaries. Just like the emotions in Riley’s brain, actuaries are self-regulated. It’s critical to keep our core beliefs at the center of the work we perform and the guidance we provide.
Actuaries, like Anxiety, arrive at better solutions when they consider all possible perspectives and share control of the conversation with other professionals.
The actuaries’ Code of Professional Conduct and actuarial standards of practice (ASOPs) help guide us in our work, and without those core beliefs, an actuary could find themselves in the same predicament that Riley finds herself. As Anxiety controls Riley’s brain throughout hockey camp, the core beliefs are discarded, and this causes Riley to act uncharacteristically. Riley knows herself to be a good person and yet she chooses to be mean to her closest friends as Anxiety attempts to help her win a coveted spot among the new hockey team members. Thankfully, actuaries take professionalism very seriously and have the Actuarial Board for Counseling and Discipline (ABCD) as an important resource to strengthen and align our professional values.
In addition to core beliefs, Riley’s brain has other checks and balances to help her navigate through life. Anxiety is meant to interact with all the emotions in Riley’s brain and work together as a team. But rather than collaborating with the other emotions during hockey tryouts, Anxiety takes control and does not consider their perspectives and advice. While Riley is playing hockey, she stops passing the puck to her teammates, and her playing suffers.
Anxiety would do better to collaborate with her colleagues inside Riley’s mind as well as on the ice. Actuaries, like Anxiety, arrive at better solutions when they consider all possible perspectives and share control of the conversation with other professionals. The best lesson for Anxiety—and for actuaries broadly—is to be ready to listen to others at the table with you … and bring others to the table when necessary. Well-informed decisions come from balanced perspectives, not only the risks you as an actuary foresee, but also from the observations and insights of others. (Please note that as a risk-mitigation strategy, in this paragraph we have left you to assign the emotions to those at the table with you, thus avoiding taking this analogy beyond the point of reasonable entertainment.)
In the end, Anxiety is rescued by Joy and the rest of the emotional team. Joy restores Riley’s core beliefs and sense of self. We watch as Riley finds a way to ground herself, regain her perspective, and move forward with her mission to finish the hockey game. Simple steps, like taking a time-out, bring balance back to all the emotions in Riley’s brain. Joy takes on a familiar leadership role, doling out different jobs for each emotion that play to their strengths. This is a key leadership trait that many of us aspire to and not enough of us master—getting the best out of each resource and putting the whole picture together for a collective win. And most importantly, remembering that our resources extend beyond the actuarial profession. We don’t get to know whether Riley made the hockey team, but her smile in the parting shot assures the viewer that balance and collaboration is key—a great reminder for all professions, not just actuaries.
We provide our greatest value when considering the voices of other professionals in our work.
We can all relate to Riley’s feelings of anxiety, both through our own experiences and by witnessing those of today’s adolescents. In interviews, the team behind the movie described how the storyline of the movie evolved over time. Anxiety, as a character, was originally considered as a shapeshifting villain, rather than the orange emotion with an explosion of hair and toothsome smile that we have grown to love. Anxiety, as an emotion, serves an evolutionary purpose and can be valued as part of the human psyche. Actuaries are often the ones at the table raising unpopular issues that no one wants to hear but everyone needs to know for informed decision-making. Actuaries occasionally get a bad rap, although—in our completely and utterly unbiased opinion—actuaries are as lovable and well-intentioned as Anxiety is shown to be. Actuaries have a critical voice and play an important role in their industry, but we provide our greatest value when considering the voices of other professionals, operating as members of a broader team.
Inside Out 2 is filled with great insights about human nature, the emotions that often drive our decisions, and our capacity for growth. Even if, after reading this article, you still don’t see Anxiety as an actuary in disguise, keep in mind that personal and professional growth are central tenets of a successful actuarial career. Our professional journey begins with exams, experience with different actuarial functions, and mentorship. As we continue in our career, we grow through experience, stretching ourselves to see the risks and opportunities in an ever-changing environment. Watching Riley grow and her brain expand with new learning reminds us that we should be seeking opportunities for growth throughout our career.
Take inspiration from Riley and make room in your mind for something new!
Endnotes
“Inside Out 2”; The Numbers; 2024.
“‘Inside Out 2’ Review: Pixar’s Vision of Teenage Turmoil”; The Wall Street Journal; June 13, 2024.
Inside Out and Top to Bottom: It’s All Connected
In Inside Out 2, Anxiety appears alongside other emotions, as it rarely arrives alone. Although it was accompanied by Embarrassment, Envy, Ennui, and a touch of Nostalgia in the movie, a sense of dread, irritability, panic attacks, and depression are also frequent companions. Occasionally, substance use disorder (SUD) steps in, attempting to control anxiety, but instead worsens the situation.
A certain bit of anxiety is healthy—it can be motivating and help us tackle challenges. Indeed, in Inside Out 2, anxiety helped Riley solve problems. However, when anxiety becomes excessive—whether in the movie or real life—it can become harmful. When it starts interfering with daily activities, it may cross the line into an anxiety disorder.
Behavioral health disorders often emerge during childhood or adolescence and can have lasting effects on an individual’s physical and mental well-being.[1] Anxiety disorders are the most prevalent mental health conditions among young people in the United States, affecting approximately 1 in 4 adolescents aged 13 to 18, and an estimated 1 in 17 experience severe anxiety.[2][3][4] In 2018, 12% of young people aged 12-17 reported having experienced a major depressive episode (MDE) in the past year.[5] The relationship between SUDs and mental health disorders is reciprocal—those with a substance use disorder are at higher risk for mental health conditions, and vice versa. Most young people with a SUD also experience a comorbid mental health disorder.
Mental health and physical health are inextricably related. Mental health conditions can lead to unhealthy behaviors, impacting the immune system, sleep, and frequently lead to self-medication with alcohol or other substances—which can lead to liver disease, cardiovascular issues, and neurological damage. Physical health disorders such as chronic illnesses, chronic pain, obesity, trauma (e.g., physical injuries), sleep disorders—just to name a few—can have a significant impact on mental health, either directly affecting neurological health or from the stress they cause (e.g., acne can cause intense social stress). It is not surprising that individuals with severe mental health disorders have life expectancy 10 to 25 years shorter than the general population.[6]
Moreover, research underscores the profound impact of inequitable social conditions, such as food insecurity and housing insecurity, on mental health.[7] Systemic racism and other forms of marginalization also profoundly influence overall health, with a particular effect on mental well-being.[8]
Historically, health care treatment paths were divided into two distinct domains—one for physical health and one for behavioral health—with minimal intersection. The Mental Health Parity and Addiction Equity Act (MHPAEA),[9] as amended by the Consolidations Appropriations Act (CAA, 2021),[10] attempted to ensure equal treatment for both physical and behavioral health care, but the separation of these domains has continued to lead to inherently unequal care for mental health and substance use disorders, often leading to disparate access to behavioral health services. MHPAEA’s analysis for quantitative treatment and financial actuarial limitations are mostly objective, but nonquantitative treatment limitations (NQTLs), including practices such as utilization management, remain challenging to assess for compliance. A 2024 MHPAEA rule introduced greater objectivity to NQTL analysis by requiring data analysis on provider networks, out-of-network provider reimbursement, and prior authorizations requirements and denials.[11] Although Medicaid is not a group health plan or an issuer of health insurance, it is a public health plan required to comply with certain MHPAEA standards.
In the United States, Medicaid is the largest payer for behavioral services, paying for approximately 26% of behavioral health spending.[12] Nearly one in five Medicaid enrollees has a behavioral health diagnosis.[13] There have been numerous Medicaid innovations over the years intended to promote behavioral/physical health integration. These initiatives focus on coordinating care across different types of providers and services, addressing both physical and behavioral health needs. Examples include reimbursing care models like Certified Community Behavioral Health Clinics (CCBHCs) and payment structures such as value-based payment models, which incentivize providers to enhance care coordination, among other quality metrics. Programs have evolved over time to include coordination with social services. The most recent model is the Innovation in Behavioral Health (IBH) Model, announced by the Centers for Medicare and Medicaid Services in 2024.[14] The IBH Model’s goal is to improve the quality of care and health outcomes for people with moderate to severe behavioral health conditions, including mental health conditions and/or SUDs. It supports special social determinants of health initiatives, holistic support, supportive housing, employment, and education programs. The IBH Model was designed to complement efforts and investments made in support of the CCBHC model.
The evolution of behavioral health care treatment and payment models require complex modeling and risk analysis, in which actuaries play a crucial role. By collaborating with public health experts, health care providers, economists, policy analysts, and data scientists, actuaries help support the creation of policies that are not only financially sound but also effective in improving behavioral health outcomes. This interdisciplinary collaboration is essential for addressing the growing challenges in behavioral health and ensuring that care is both accessible and sustainable for future generations.
Endnotes
[1] Access to Behavioral Health Services for Children and Adolescents Covered by Medicaid and CHIP; Chapter 3; Medicaid and CHIP Payment and Access Commission; 2021.[2] “Thirty-year trends of anxiety disorders among adolescents based on the 2019 Global Burden of Disease Study”; General Psychiatry; April 3, 2024.
[3] “Anxiety Disorders in Children and Adolescents”; American Family Physician; December 2022.
[4] “Any Anxiety Disorder”; National Institute of Mental Health.
[5] “Mental Health in America—Youth Data 2018”; Mental Health America.
[6] “The relationship between physical and mental health: an update from the WPA Working Group on Managing Comorbidity of Mental and Physical Health”; World Psychiatry; February 2023.
[7] “The Role of Social Determinants of Health in Promoting Health Equality: A Narrative Review”; Cureus’; Jan. 5, 2023.
[8] “Poverty, Racism, and the Public Health Crisis in America” Front Public Health” Sept. 6, 2021.
[9] Pub. L. 110-343, Oct. 3, 2008, as amended by the Patient Protection and Affordable Care Act, Pub. L. 111-148, Mar. 23, 2010, and the Consolidated Appropriations Act, 2021, Pub. L. 116-260, Dec. 27, 2020. Additionally, requirements related to mental health parity were included in the 21st Century Cures Act (Cures Act), Pub. L. 114-255, Dec. 13, 2016, as amended by the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act (Support Act), Pub. L. 115-271, Oct. 24, 2018.
[10] Section 203 of Title II of Division BB of the Consolidated Appropriations Act, 2021 (CAA, 2021), enacted on December 27, 2020, amended MHPAEA. Public Law No. 116-260, 134 Stat. 1182 (2020).
[11] MHPAEA Final Rule, September 9, 2024.
[12] Integrating Behavioral Health into Medicaid Managed Care: Design and Implementation Lessons from State Innovators; Center for Health Care Strategies; April 2016.
[13] Ibid.
[14] “Innovation in Behavioral Health (IBH) Model”; Centers for Medicare & Medicaid Services.