MENTAL HEALTH REFORM: What It Would Really Take

Gerald Minsk used to drop acid and smoke pot to help quell paranoid delusions that Boston's North End mafiosi were conspiring against him. Yes, it's crazy to take hallucinogens to soothe your hallucinations. But that's what untreated mental illness does to you. It can also leave you jobless and sleeping under the Boston University bridge. That's what happened to Minsk, anyway, in the 1970s. For years, his bipolar disorder was virtually ignored as he cycled in and out of jails, mental hospitals and community centers, none of which took the time, or had the resources, to treat him properly.

Millions of Americans are treated the same way. As a rule, mentally ill people are no more likely than their neighbors to be violent. But untreated mental illness can have horrific results. Andrew Goldstein asked to be hospitalized in New York because he was terrified of phantom voices. Instead, budget-conscious officials most often referred him to short-term emergency care. Last year, in a psychotic state, he shoved a woman from a subway platform to her death under the wheels of a train.

Though tragedies like this one make headlines, the real shock is what happens to the vast majority of mentally ill people. Most Americans with mental illness simply aren't treated. Of the 2 million who suffer from schizophrenia, for instance, more than half receive substandard care. Only a third of those with serious depression receive any treatment. Reformers have tried to call attention to these problems for years--former First Lady Rosalynn Carter has been an advocate since the '60s--but the mentally ill have a powerful new ally.

Tipper Gore, wife of the Vice President, has organized a first-ever White House conference on mental health, which takes place next week. Gore, who disclosed in the run-up to the conference that she was treated for depression in the early '90s, has prodded her husband's boss to ask Congress to spend more money to treat the mentally ill. President Clinton backs a bill in Congress to force employers to help too by providing equal insurance coverage for mental and physical health. (Currently, insurance plans can charge higher co-payments for psychiatric visits than for other medical care.) Clinton aims to set an example by announcing at the conference that the Federal Government will begin providing its employees equal benefits for mental and nonmental ailments.

Even if all the proposals become law, they will represent only the first steps in solving the crisis of the mentally ill. There's not much political benefit to pushing the cause of people with mental disorders, and over the past 30 years governments have done little to fulfill a promise made by President John F. Kennedy in 1963 to subsidize mental-health services in every community.

Instead, communities have hired a lot of police, and today cops are the primary care givers for most of the unemployed mentally ill. That's because 200,000 of them are homeless, according to the National Alliance for the Mentally Ill, an advocacy group. Another 200,000 are incarcerated, usually as a result of petty crimes. Fewer than 70,000, on the other hand, live in state mental hospitals. And according to a study by Maryland researchers, less than 10% of Americans with schizophrenia are treated in the smaller community programs envisioned by Kennedy-era reformers.

Attacking this problem all at once is impossible. It would take billions of dollars. The state of Virginia alone would have to spend $500 million to begin providing adequate community treatment, according to a 1998 report prepared for it by consultants. Virginia's Governor, Jim Gilmore, has proposed spending $41 million instead. The Clinton plan would increase the mental-health grants that go to all states by just $70 million next year, to $358 million in all.

In Congress, two Senators who have seen family members with mental illness benefit from modern treatments are trying to improve access to care for others. Republican Pete Domenici of New Mexico and Democrat Paul Wellstone of Minnesota have introduced a bill that would force employers to provide the same level of coverage for mental and physical illnesses. Although the bill would represent the most meager of advances--it would help only those well enough to work--its passage will still require a monumental lobbying effort. Business groups are already working against it, saying it's part of a liberal package of insurance reforms that would raise their costs.

Domenici and Wellstone point out that the legislation is a solid long-term investment, since it would help people get treated before their illnesses become so severe that they lose their jobs or hurt themselves. Even business lobbyists admit that the cost increases for mental-health insurance will be small (maybe 1%). But they fear it will open the door to other mandates as well. "You have to remember that the Patient's Bill of Rights is being considered too," says Kate Sullivan of the U.S. Chamber of Commerce, referring to the proposal in Congress to make it easier for people to get around the cost restrictions of managed care. "So you're talking about 1% here and 1.5% there, but in the aggregate, you're looking at a 6% increase, which is huge."