Mental Health and Substance Abuse Coverage Under Health Reform

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Abstract
Prologue:Over time, the delivery and financing of mental health and substance abuse care have evolved into a complex patchwork of services. The result has been gaping holes in the public delivery system for the poor and private insurance that runs out too quickly for many who could benefit from care. To remedy this situation, the reform of mental health and substance abuse care received a high profile on the President's Task Force on Health Care Reform, due in large part to the advocacy of the vice-president's wife. Tipper Gore. She served as co-chair of the task force's Working Group on Mental Health along with Bernard Arons, acting director of the Center for Mental Health Services, Department of Health and Human Services (HHS), and lead author of this paper. Indeed, all of the authors here were deeply involved with the working group and the vision of moving the nation's mental health system toward full integration with its acute health care system by 2001 under the president's health reform plan. Richard Frank, an economist, served on the mental health working group and is a professor in the Department of Health Policy and Management, The Johns Hopkins School of Hygiene and Public Health. Howard Goldman also served on the working group and is professor of psychiatry and director of mental health policy studies at the University of Maryland. He holds degrees in medicine and public health and a doctorate in social welfare research. Economist Thomas McGuire is a professor at Boston University and served as a consultant to the working group and to the National Institute of Mental Health. Sharman Stephens is a health policy analyst in the Office of the HHS Assistant Secretary for Planning and Evaluation. She holds degrees in nursing and public health and was also a member of the mental health working group. President Clinton's health care reform proposal articulates a complete vision for the mental health and substance abuse care system that includes a place for those traditionally served by both the public and the private sectors. Mental health and substance abuse services are to be fully integrated into health alliances under the president's proposal. If this is to occur, we must come to grips with both the history and the insurance-related problems of financing mental health/substance abuse care: (1) the ability of health plans to manage the benefit so as to alter patterns of use; (2) a payment system for health plans that addresses biased selection; and (3) preservation of the existing public investment while accommodating in a fair manner differences in funding across the fifty states.