What Price Mental Health?

By Janice Castro

When Jennifer Wilbert of Harrisburg, Pennsylvania, developed schizophrenia at 16, she began a distressing odyssey through the mental-health-care system. Overwhelmed by dangerous delusions, terror and frequent bouts of depression, she needed immediate hospitalization. That is when her parents, Rob and Joan, discovered that their insurance would pay for only 30 days of care. It was not enough. Jennifer, who is now 21, was hospitalized at first for four months. To care for her daughter with constant supervision at home, Joan Wilbert took a leave of absence from her job as a clerk at the state department of revenue and lost her seniority. Now the hospital is suing the family for $51,000, the cost of Jennifer's uninsured care. Says Rob, who is 57: "I had a heart attack at age 45. I was hospitalized for five weeks. Then I had rehabilitation. I saw the bills. They were outrageous. The treatment didn't cost us a cent. I think that anyone who has a brain disease should have the same coverage as someone who has heart disease."

He is not alone. Comprehensive mental-health care is among the medical benefits that President Clinton is thinking about guaranteeing to all Americans. Its chief advocate: Tipper Gore, who heads the mental-health section of the White House task force. During a recent evening session in the Roosevelt Room, Clinton discussed the issue with Mrs. Gore, the Vice President, Health Secretary Donna Shalala and members of the mental-health working group. Joining the 90-minute briefing, Clinton questioned the advisers and listened closely as Mrs. Gore explained how many severely disabled Americans are going without help. "I know," said the President, telling the group that he had stopped to talk to mentally ill homeless people during his early morning jogs around the streets of Washington. Said Clinton: "We need to do something about it."

Ensuring care for the severely disturbed, however, is only a small part of the new mental-health benefits under consideration at the White House. The President would meet little resistance in proposing such coverage. Only about 5 million Americans suffer from such conditions as severe depression and schizophrenia. But another 34 million people at any given time need treatment for lesser problems like moderate anxiety and depression. As he nears his deadline of mid-June for presenting his health-care reforms to Congress, Clinton is trying to decide whether to guarantee coverage of everything from hospitalization and psychotherapeutic drugs to open-ended talk therapy.

The problem is the cost. Mental-health treatment accounted for 10% of all U.S. health spending, or $67 billion, in 1990. And yet only 1 in 5 victims of all types of mental disorders gets treatment. Extending broad coverage to all Americans could double the bill -- and then some.

Besides covering more people, the President must decide whether to go along with pleas from the mental-health lobby for "parity" with other medical coverage, which would mean at least an 80% reimbursement of all mental-health treatment. As the Wilberts learned painfully, many insurers now sharply limit access to mental-health care and reimburse only a fraction of the costs, usually a maximum of 50% after high deductibles. Providing such coverage for the severely disabled alone would cost Americans $6.5 billion more a year, according to the National Institute of Mental Health.

One solution may be to offer different levels of coverage for conditions of varying severity. The White House task force's suggestions on how to do that have included limiting the number of talk-therapy sessions for moderately distressed patients, depending on the problem. But who will decide who qualifies for more help? The President may turn for guidance to a new definition of "serious mental illness" announced last week by the Center for Mental Health Services -- but if he does, caution is advised. The Center's definition includes those who are so impaired by such symptoms as sleep disturbance, low energy and feelings of helplessness that they have trouble eating, bathing, dressing and managing money. Such patients may now get free or very cheap treatment at state and local clinics that receive federal funds. Many mental-health groups object to the definition, contending that it is too vague and would include many people who are not severely impaired, thus overtaxing the system and narrowing access to benefits for the truly needy.

There is broad consensus among medical experts and business executives that mental-health coverage, accompanied by reasonable restraints, would practically pay for itself by curbing the indirect costs of mental illness. The National Institute of Mental Health estimates that lithium alone has saved the U.S. economy more than $40 billion since 1970 by stabilizing severely depressed Americans and making it possible for them to return to work. Reducing other harmful side effects of psychological disturbance would yield further savings. "One of the biggest causes of lost days at work is depression," says Mary Jane England, president of the Washington Business Group on Health. Those days cost employers an estimated $17 billion in 1989.

, Moreover, one of the largest hidden costs of mental illness is already in the U.S. health-care bill: because many sufferers are unaware that their condition is a psychiatric problem like depression or panic disorder, millions handle their problems only by going to the family doctor. Several studies have estimated that half of all general medical care is sought by people who have no identifiable physical illness but are plagued by psychological problems with such symptoms as anxiety, sleeplessness and lack of energy. If that is true, billions of dollars in primary care may be wasted by physicians studying the wrong part of the patient's body.

The need for better mental-health coverage is clear enough, yet persuading Congress and the public to pay for dramatically expanding it will be difficult. No other area of medicine is so plagued by ignorance, suspicion and misunderstanding about its value. Unlike a purely physical ailment like a broken leg, it is difficult to tell when psychiatric problems have been fixed. In addition, psychoanalysts and other professionals often disagree on the best course of treatment, lending an aura of faddishness at times to therapy.

Yet mental-health professionals see the Clinton reform effort as their main chance to achieve parity with their medical brethren. Says Frederick Goodwin, director of the National Institute of Mental Health: "If one is going to question the use of psychotherapy for the stress of going through a divorce, then one should also question physical therapy to rehabilitate a knee so a patient can return to skiing." Even so, Clinton's plan is likely to offer only half a loaf. As Tipper Gore told a Senate committee two weeks ago: "The final plan may not contain everything I would like it to. Anyone who is passionate about any aspect of health care must be prepared for that." Those words contain a good deal of political wisdom for shaping all the aspects of Clinton's health-reform plan.

With reporting by Dick Thompson/Washington and James Willwerth/Los Angeles