A Defining Moment for Mental Health Care : Insurance: The national effort to reform medical coverage offers a chance to start treating psychological ailments the same as physical ones. The tough question is who will pay.

Sandra had been diagnosed with manic depression in 1973 at age 19. But, with lithium and psychiatric counseling, she coped well. She even held down a low-paying job.

Then, in 1986, she moved to Southern California. Her woes were about to begin.

Because her income was meager, she found psychiatric care through a San Fernando-based public clinic that charged her on a sliding-scale fee. However, in 1990, state budget cutbacks left her with just the health insurance provided by her employer.

But there was a problem.

Under her employer’s insurance plan, Sandra was reimbursed only $20 for every visit to her psychiatrist, who charged $120 a session, and Sandra couldn’t afford the difference. So she stopped seeing him.

Desperate to continue her therapy, Sandra pleaded with other psychiatrists.

“I said, ‘Please, can you see me for $25?’ But they would only see me for 15 minutes instead of an hour,” she recalled.

Finally, Sandra explained her dilemma to an internist who was treating her for arthritis. The doctor agreed to take over prescribing Sandra’s lithium and performing the frequent blood tests necessary to ensure a safe dosage. But three years later she still has no psychiatric therapy.

“It’s so ironic that I only pay 10% of the bill for my arthritic care and would have to pay 90% for my psychiatric care,” Sandra says. “Mental health is given such a low priority.”

*

Sandra’s story is the kind that has been voiced repeatedly in recent months before the national health care reform subcommittee on mental health, led by Tipper Gore.

And if Gore and other mental health advocates have their way, these inequities will soon cease.

The early hints from Washington suggest that Gore’s subcommittee will recommend to the President and Congress that people with mental health disorders be guaranteed coverage and that existing benefits be expanded.

About 5 million adults and one million children suffer from severe mental disorders, although as few as 25% get help, a recent study revealed. Two-thirds of those people have health insurance, but it is rarely adequate to cover treatment, expert say.

But while mental health-care reform is brimming with promise, implementing changes will be fraught with problems, experts predict. They point to a rat’s nest of complicated questions, such as:

* How will insurers, employers and lawmakers decide what conditions are covered and what are not?

* Will poor or unemployed Americans be left out?

* Will Americans overuse a more generous benefit, if available, and exhaust it?

Potentially most troublesome are issues arising from the shift to a managed-care benefit which is becoming more popular. Under this type of plan, what happens between a therapist and patient is closely controlled by a third party: the insurer. Some critics suggest that under such a system, employers are only concerned with keeping costs low.

But experts are confident that these questions can be worked out.

“I don’t want to sound like a Pollyanna, but this (national plan) is looking suspiciously, pretty darn good,” says Richard Van Horn, chief executive officer of the Mental Health Assn. of Los Angeles. “It looks like we might have full parity for at least the severe mental health illnesses. This is what is so exciting.”

Others are worried:

“I’m optimistic from the standpoint that Mrs. Gore and the task force has really embraced the notion of a more general mental health and substance abuse benefit,” says Dr. Alex Rodriguez, chief medical officer of Preferred Health Care of Wilton, Conn., the largest U.S. provider of managed mental health care services.

But lawmakers and financial executives, he adds “are conditioned (to believe) that mental health benefits are a waste, are uncontrollable and frequently abused. A leap of faith that those things won’t happen will have to occur among those people making the executive decisions.”

*

As it stands, few Americans receive the same kind of insurance coverage for mental disorders as they do for physical disorders.

For example, under most private indemnity plans, mental health care is covered at 50% of total costs, usually with low annual and lifetime limits. In comparison, physical ailments are usually covered at 80%.

Medicaid generally covers a maximum of 30 days inpatient treatment and no more than 20 outpatient treatments, Rodriguez says.

And many HMOs severely restrict benefits, mental health experts say. According to Dr. Michael Freeman, president of the Institute of Behavioral Healthcare in San Francisco, many HMOs offer no inpatient psychiatric care and extend outpatient care only in a “crisis” and with a limited number of treatments.

People who are indigent and have not filed the paperwork to receive Medicaid services must rely on overburdened free clinics where resources are stretched.

David, 41, of Los Angeles, worked as a clinical research chemist before being laid off a few years ago. Stricken by chronic depression, he lost his home and savings. He found the public mental health clinics unsatisfactory.

“I didn’t have transportation to get there, so I would take the bus or beg for a ride,” he says. “When I got there, there would be lines out the door, even at 7 in the morning. You would have to wait all day, and in a lot of places you couldn’t bring food inside. I’m a diabetic and I have to eat. So I just found it impossible to get through the agencies.”

David finally obtained antidepressant medication through a program for the mentally ill who are homeless, but he still isn’t receiving psychiatric counseling.

He would like to get back on his feet, but overcoming depression is the first step.

“With my depression, everything has been monumentally hard,” he says.

Increasingly, the American public is shifting to the position that situations like David’s or Sandra’s are fundamentally unfair. Powerful proponents for change include: Tipper Gore, who has a master’s degree in psychology; former First Lady Betty Ford, who was treated for substance abuse; Sen. Pete Domenici (R-N.M.), who has a child with mental illness, and former First Lady Rosalynn Carter, a longtime advocate for mental health care.

Moreover, mental health providers have joined forces to press their case for equality. A document released last month and signed by 90 health care firms calls for non-discrimination, equity and choice in mental health care.

Finally, research has given a huge boost to the argument that mental health disorders are not illnesses that people opt to have or are simply too weak to overcome.

“I think there is universal agreement in the health care community that behavioral health care requires the same coverage as other medical conditions,” says Freeman, whose nonprofit organization has helped unify the mental health community.

“The scientific research in the last 10 years shows most of the most severe, chronic, psychiatric illnesses are brain-based illnesses. And the prevalence of these conditions (and lesser ones) is so vast--one out of every five Americans has a diagnosable condition at any given time.”

Anxiety, panic and obsessive-compulsive disorders; manic and chronic depression; schizophrenia, and autism and attention-deficit disorder in children all have evidence of a biological cause, says Debbi Honorof of the National Foundation for Depressive Illness.

“I don’t know how people can distinguish between depression and diabetes,” Honorof says. “They are both biological.”

Mental health professionals are becoming increasingly frustrated with what they say are arbitrary and discriminatory decisions made by insurers.

For example, Honorof says, Parkinson’s disease and schizophrenia are both brain-based illnesses. But Parkinson’s is considered a physical illness under all insurance plans, usually covered at 80% of costs, while schizophrenia is considered a mental illness under most plans, usually eligible for only 50% coverage with other stringent annual and lifetime caps.

But even if Congress agrees that unequal coverage is unfair, the costs of expanding mental health benefits may threaten reform. Mental health costs consume 11%-14% of the national health care budget.

“Expanding mental health benefits seems fair and right. But fairness and rightness will come up against the need to define what you can pay for,” Rodriguez says.

*

Rodriguez and other experts predict that consumers will not see significant changes in mental health coverage in the near future.

But, he says, “within each state, there will be opportunities to (expand) the benefit.”

In Maine, which has one of the most progressive mental health plans in the nation, lawmakers voted last year to give equal coverage to certain severe disorders such as schizophrenia, bipolar illness, autism, paranoia, major depression, panic disorder and obsessive-compulsive disorder. Equal coverage of these illnesses will be phased in over five years, says the author of the legislation, Rep. Susan Dore.

“It’s discrimination not to cover these illnesses equally,” Dore says. “Can you imagine someone with cancer having a lifetime $25,000 cap on their insurance? What insurers are saying to people with mental illness is ‘You are to blame for your illness.’ ”

Who Gets Treated

More than one-quarter of Americans have a diagnosable mental health condition, a recent national study of 20,291 adults found. But few seek treatment.

Percent of Population Surveyed No illness or treatment 65.3% Diagnosable illness, but untreated 20% Diagnosable illness, treated 8.1% No diagnosable condition, but treated 6.6%

Source: Archives of General Psychiatry

Where Americans Get Care

The lack of adequate health insurance for mental illness means that many Americans seeking treatment rely on free volunteer services or general medical doctors for care.

Percent of population seeking care Specialty mental health and addiction services 37.5% Volunteer support network 39.7% General medical services 11.1% Other human services 11.7%

Source: Archives of General Psychiatry