Am J Psychiatry 1993; 150:7-18
Copyright © 1993 by American Psychiatric Association
Psychiatric care and health insurance reform
SS Sharfstein, AM Stoline and HH Goldman
Sheppard and Enoch Pratt Hospital, Baltimore, MD 21285-6815.
Concerns about cost, access, and quality of health care in the United
States have led to a variety of legislative proposals that would reform our
health care system and its financing. Health insurance benefits for mental
illness, including substance abuse, are treated differently from
medical/surgical benefits, with stricter limits on outpatient visits and
hospital days. Medicare, Medicaid, and most private health insurance plans
contain this historic disparity of coverage for mental illness compared to
general medical illness. Psychiatric services are also distinguishable
because of the large public sector reimbursement for mental illness
treatment and support. Principles for a more equitable design of mental
health benefits include a non-discriminatory approach; payment on the basis
of service rather than diagnosis; application of cost containment for care
of mental illness on the same basis as care of general medical illness;
retention of the public sector as a backup system for high-cost, long-term
care; encouragement of lower-cost alternatives to the hospital through the
development of a continuum of care; and a recognition of the distinction
between psychotherapy and medical management. All current approaches to
universal health care fall short of these principles. A research agenda is
needed now more than ever in order to articulate the case for complete
coverage of mental illness and substance abuse.
