Academic journal article The Hastings Center Report

Minds and Hearts: Priorities in Mental Health Services

Academic journal article The Hastings Center Report

Minds and Hearts: Priorities in Mental Health Services

Article excerpt

To care for people with mental illness is to live in a world of inescapable misfortune and tragic choices. Mental illness strikes with a random yet pandemic quality, producing at its worst nightmarish hallucinations, crippling paranoia, unrelenting depression, a choking sense of panic, and uncontrollable obsession - and even in its milder manifestations it produces many other oppressions. Approximately one in three Americans will experience some form of mental disorder at some point in their lives, and according to one estimate, one in every 6.4 adults is currently suffering from some form of mental illness.[1] This figure comes to 41.2 million people and climbs higher if substance abuse is included. A significant number of these - more than 1.7 million Americans - suffers from a persistent and severely disabling condition, such as schizophrenia. The costs of caring for these patients and those whose illness is episodic, curable, or only mildly debilitating have reached $136.1 billion per year.

As if the tragedy of illness were not pain enough - for individuals with mental illness, their families, and the community - as a society we face additional pain as we are pressured to choose which ill people we will treat and with what services. As health care reform moves forward with the aim of providing affordable, appropriate health care that is available to all, there will be pressure to examine whether any health services are less important or dispensable than others. It is unlikely that mental health will escape scrutiny. Indeed, one of the most serious issues that will have to be faced by the mental health community is how it can participate in the health planning process.

Given the past and present dismal plight of mental health services, both its patients and its providers have good reason to be concerned about reform. Historically, mental health services have not received the same support as physical health.[2] private and public funding permit "carve outs" in mental health coverage that provide fewer benefits than those allowed for physical health. Private insurance customarily restricts mental health benefits more stringently, setting caps on numbers of hospital days or outpatient visits, or imposing annual or lifetime dollar limits for mental health services.[3]

Insurance policies, for example, typically limit hospital care for persons

with mental illness to thirty days a year, according to a 1991 survey of employer-provided coverage conducted by the Health Insurance Association of America. While 99 percent of insured individuals have private coverage for inpatient mental health care, in only 37 percent of these cases is the mental health coverage' equivalent to that for other illnesses.[4] The same is true for outpatient care: although 98 percent of persons with private insurance are covered for outpatient mental health benefits, only 3 percent have coverage equivalent to that for other illnesses. Psychotherapy sessions are generally limited to ninety visits a year with a 50 percent copayment. Health maintenance organizations (HMOs) customarily restrict therapy to thirty sessions a year with a 50 percent copayment.[5] Spending caps (lifetime or annual) limit coverage of disorders such as schizophrenia, bipolar disorder, and autism because of the presumed high cost of treatment and uncertainty of successful outcomes. Unfortunately, mandates generally provide uniform limits on services without regard to the severity of the condition or the effectiveness of the treatment.[5] The public system's provision of care is not much better. With strained, if not reduced budgets, and fragmentation in services among levels of government, those in need of mental health care are often either stricken from the rolls or simply fall through the cracks of a highly fragmented system. In a word, mental health continues to be the poor stepchild of the health care delivery system. As someone once quipped, mental health care is more likely to be a "plea for service" than "fee for service. …

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