A few made all the difference for Mary Ann Beall and Raymond Bridge. For years, they watched helplessly as their daughter, diagnosed with paranoid schizophrenia, bounced from hospital to hospital and neatly stapled bills arrived promptly in the afternoon mail. The couple ran through the psychiatric coverage under five insurance plans in six years and feared losing their Arlington, Va., home as their unpaid bills topped $250,000. But in 1989, a miracle occurred: Doctors realized their daughter suffered from epilepsy, not schizophrenia. Changing her diagnosis, they moved her illness from the realm of psychiatry into neurology. And presto -- full insurance coverage. Says Beall: "She's the same person, struggling with the same symptoms. The only thing that's changed is the label."
It is cases like this that advocates count on to persuade lawmakers to right a long-standing wrong as they draft health reform. They hope the final plan will offer full catastrophic insurance protection for people with mental illness, who under the current health system face restrictions on care, high copayments, limited reimbursement for prescription drugs and restraints on services. And advocates' optimism soared early last year when Tipper Gore called for "parity" in mental health coverage, vowing that President Clinton's reform plan would cover mental disorders equally with other medical conditions.
Vox pop. Her views seem to reflect Americans' sentiment. A poll by the David L. Bazelon Center for Mental Health Law, to be released this week at a press conference with former first ladies Rosalynn Carter and Betty Ford, found that two thirds of Americans favor including mental health coverage in any basic national benefits package. Three quarters say they want to cover mental health problems to the same extent as physical illness. And 60 percent would prefer full -- rather than limited -- mental health coverage, even if it cost them $100 more per year.
Congress appears less convinced than the public that mental health and substance abuse problems can be covered economically. Two national polls last week showed the Clinton health plan -- the only alternative to offer a specific blueprint for mental health benefits -- losing popular support, a shift not lost on lawmakers. Other reform schemes, such as Sen. John Chafee's bill, include coverage for "severe" mental illness but relegate the details of all medical benefits to a national board. And some plans simply omit any reference to mental ills.
Few politicians, however, will go on record opposing mental health coverage altogether. Even the National Association of Manufacturers, which earlier this year labeled mental health benefits unacceptably expensive, recently recanted its position. Yet fearsome images -- among them, Woody Allen soliloquizing on a couch, and the high mental health insurance costs that plagued businesses in the early 1980s -- linger in many lawmakers' minds. As one lobbyist put it: "There's a feeling that by including mental health, they'd be taking the finger out of the [financial] dike." full -- rather than limited -- mental health coverage, even if it cost them $100 more per year.
Congress appears less convinced than the public that mental health and substance abuse problems can be covered economically. Two national polls last week showed the Clinton health plan -- the only alternative to offer a specific blueprint for mental health benefits -- losing popular support, a shift not lost on lawmakers. Other reform schemes, such as Sen. John Chafee's bill, include coverage for "severe" mental illness but relegate the details of all medical benefits to a national board. And some plans simply omit any reference to mental ills.
Few politicians, however, will go on record opposing mental health coverage altogether. Even the National Association of Manufacturers, which earlier this year labeled mental health benefits unacceptably expensive, recently recanted its position. Yet fearsome images -- among them, Woody Allen soliloquizing on a couch, and the high mental health insurance costs that plagued businesses in the early 1980s -- linger in many lawmakers' minds. As one lobbyist put it: "There's a feeling that by including mental health, they'd be taking the finger out of the [financial] dike." per year. Congress appears less convinced than the public that mental health and substance abuse problems can be covered economically. Two national polls last week showed the Clinton health plan -- the only alternative to offer a specific blueprint for mental health benefits -- losing popular support, a shift not lost on lawmakers. Other reform schemes, such as Sen. John Chafee's bill, include coverage for "severe" mental illness but relegate the details of all medical benefits to a national board. And some plans simply omit any reference to mental ills.
Few politicians, however, will go on record opposing mental health coverage altogether. Even the National Association of Manufacturers, which earlier this year labeled mental health benefits unacceptably expensive, recently recanted its position. Yet fearsome images -- among them, Woody Allen soliloquizing on a couch, and the high mental health insurance costs that plagued businesses in the early 1980s -- linger in many lawmakers' minds. As one lobbyist put it: "There's a feeling that by including mental health, they'd be taking the finger out of the [financial] dike."
Clinton compromise. Indeed, the Clinton administration itself gave in to similar cost concerns: Last November, it sharply cut back its initial coverage plan for mental health when Health Care Financing Administration actuaries deemed the coverage too costly to sell to Congress. The final version of the plan promises full coverage by 2001, preserves universal coverage, eliminates lifetime limits on the amount paid for treatment and provides coverage for prescription drugs and a variety of outpatient services. But it also imposes in the interim stricter limits on services and substantial copayments. Moreover, it creates a complicated system of tradeoffs that would allow patients to obtain some forms of outpatient care like day-treatment programs and psychotherapy beyond 30 sessions by "trading off" their rights to coverage of hospital stays.
Advocates now fear Congress might pass Clinton's interim plan but nix the goal of full coverage in 2001 -- leaving them stuck with a relatively meager benefit, only slightly better than that currently offered by many businesses. While all say the revised coverage is better than none, they worry that arbitrary limits on services will once again leave the most needy with inadequate treatment and that trade-offs will create a bureaucratic nightmare. And it is not clear that the full range of services now offered the mentally ill through Medicaid will be preserved under health reform. "Where the Clinton plan ends is brilliant," says Michael Hogan, director of Ohio's Department of Mental Health. "Where it starts is a disaster." Even Tipper Gore, sources say, was less than pleased with the revised plan. In an interview with U.S. News, however, she emphasized the plan's progressive aspects and goal of parity, saying she was "very pleased with the direction in which we are going."
No limits? A growing number of managed care experts now recommend using cost control systems for mental health that rely on management by "medical necessity" and controlling in-hospital costs rather than imposing specific limits on benefits, as Clinton's interim plan would do. Some corporations have adopted this approach successfully. And state governments, eager to stop hemorrhaging of Medicaid funds, are also trying it: Massachusetts, which privatized its Medicaid system in 1992, offered patients carefully managed services without set limits and saved $47 million over expected costs in a single year.
The "no limits" approach does not meet with universal approval: "There are too many institutions out there used to a blank-check world," says Helen Darling of Xerox Corp., which abandoned an unlimited benefit sys
