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."
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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.
