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agement procedures can be used to restrict access to certain levels and types of care and to pressure practitioners to limit lengths of stay (Schlesinger et al., 1996). These practices and incentives not only reduce expenses but also exert both subtle and overt pressures on individuals with mental health and substance abuse problems to leave or disenroll from the plan. Critics of managed behavioral health care plans often focus on the potential for reduced access and undertreatment (Boyle and Callahan, 1995; NCQA, 1996).

The stigma associated with mental illness and substance abuse also contributes to the potential for undertreatment and insufficient access to care (Mechanic et al., 1995). Individuals with mental health and substance abuse problems may be reluctant to publicly acknowledge their illnesses and seek care. In addition, when they seek care for other medical problems, the relevance of mental health and substance abuse problems may not be evaluated. As discussed in Chapter 2, primary care practitioners in general are not trained to identify the need for mental health and substance abuse treatment and may not be comfortable making interventions and referrals if they suspect a problem. Thus, the characteristics of these illnesses increase the susceptibility of individuals with mental health and substance abuse problems to being underdiagnosed and undertreated.

Men, women, and children who suffer from mental illness and substance abuse tend to be vulnerable in several ways. Individuals who have a serious mental illness or a dependence on alcohol and other drugs are likely to have inadequate economic and social supports, may have difficulty in advocating for their own health care needs, and are at high risk of disease, injury, and death. A lack of access to behavioral health services can aggravate their needs for acute and chronic medical care and may increase the cost of health care. More generally, mental illness and substance abuse problems and the costs associated with treating those problems also place large burdens on families, communities, and the criminal justice system (Mechanic et al., 1995). Inadequate care for mental illness and substance abuse increases the strains that families and employers experience and shifts the burden of intervention from the medical system to the criminal justice system and may affect public safety. Access to treatment for mental health and substance abuse treatment therefore has direct implications for employers, communities, and the public authorities for the Medicaid, mental health, substance abuse, and criminal justice systems.

The issue of parity of coverage for mental health and medical care achieved widespread national attention during the summer and fall of 1996, when Congress debated amendments to the Kassebaum-Kennedy bill on job-to-job coverage. The Senate version of the bill included a provision advocating parity of mental health coverage with medical coverage but the provision was dropped from the final version of the bill passed by Congress and signed by President Bill Clinton. House and Senate negotiators later agreed to a compromise version that requires parity for existing lifetime or annual limits but does not mandate mental health services. The provision does not include substance abuse or chemical dependency,



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