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By Rosalynn Carter

The Washington Post

Susan B. became manic-depressive in her teens and attempted suicide twice by age 20. After proper medication and therapy, today she is doing well and plans to enter a seminary soon to share her faith and resolve with others. Because her insurance covered only 50 percent of the cost of a lengthy hospital stay and another stay was not covered because it related to a "pre-existing condition," she and her husband had to file for bankruptcy with medical bills more than $20,000. In a letter to me, Susan asked, "What do others do who have less?"

Not too many months ago there was great hope, indeed optimism, in the mental health community that health care reform would enable us finally to eliminate one of the major forms of discrimination against people with mental illness -- the historic lack of decent, equitable and comprehensive health insurance. There was hope that people with mental illnesses would be included on a par with physical illnesses in the proposal. This courage and determination shown by the Clinton administration has recently encountered opposition. Hope has begun to fade, and optimism has given way to apprehension.

Hardly a day passes without some published article commenting on concerns about increased costs, uncertainty about the accuracy of cost projections, reservations about managed competition, the advisability of some phase-in of coverage for mental health over a number of years, or the magnitude of need for long-term care. Clearly, some hard decisions will have to be made.

While it is still likely that the result of those decisions will be better overall health care, it is almost certain that some limits will be placed on health care benefits. We cannot expect to address all health care needs for everyone at the same time. I believe that the mental health community understands and accepts this and will work toward reasonable accommodation.

The special concern of the mental health community stems not from the real complexities of the task, but from indications that mental health care will have extraordinary and discriminatory limits imposed based upon faulty stereotypes and outdated information.

Hope for the mental health community lies in growing evidence that negates the old stereotypes. For example, mental illness is now definable like physical illness; experienced clinicians agree on a given diagnosis 80 percent of the time. Mental illness can be effectively treated at rates that compare favorably with the treatment of some physical illnesses; the efficacy rate for the treatment of acute episodes of schizophrenia is 60 percent, but for angioplasty, 41 percent, and for atherectomy, 52 percent.

The availability of appropriate treatments clearly can save the nation money. A study in the Archives of General Psychiatry in 1980 estimated that the use of lithium and other treatments for manic-depression was saving the U.S. economy more than $ 400 million a year. In another study, between 1987 and 1991, the federal CHAMPUS program, the military's health insurance plan for dependents, demonstrated savings of $ 148 million by using a system of mental health care targeted to children in the Tidewater area of Virginia.

Currently, economists and actuaries are debating the costs and potential offsets of including comprehensive mental health coverage in national health care reform. Although we do not have a final answer yet, some specific experiences suggest true economies can result.

Health insurance plans that provide for an appropriate array of services result in more use of lower-cost services, such as outpatient visits, and less use of higher-cost services, such as inpatient hospitalization. McDonnell Douglas introduced an employee assistance plan that managed individual and family health care yet reduced mental health care costs by 50 percent and physical health care costs by 29 percent over four years. Chevron created a plan doubling the number of people eligible for coverage yet increasing annual cost from only $ 9.2 million to $ 9.8 million.

Not only can we provide more efficient care, but mental health care can reduce costs for physical illnesses. The Group Health Association, a Washington HMO, for example, reported that once patients started using mental health counseling benefits, they reduced their nonpsychiatric physician visits by 30.7 percent and lab/x-ray services by 29.8 percent. Plans offering comprehensive and equitable coverage for mental disorders have not "broken the bank"; the percentage of costs represented by mental disorders in these plans has plateaued at about 11 percent. There has not been a groundswell of people rushing for services and creating overwhelming demand as some fear.

In addition, we have learned a great deal in the past 20 years about how to treat severe mental illness effectively in a community-based system. Psychiatric rehabilitation and case management help those who have been disabled by major mental illness re-learn skills lost in the course their illnesses -- taking care of their daily needs, returning to work and getting along with colleagues. These services generally offset hospitalization costs and increase an adult's ability to live independently. For children, intensive community services can prevent the painful family separations that occur when a child is placed in a residential treatment center.

President Clinton has repeatedly said that the most expensive choice in health care is doing nothing. This is especially true for people with severe mental illness who, without community based services, are likely to incur high costs in the health care system for hospitalization and emergency care, in the social welfare system for income and housing to survive, and in the criminal justice system because those with mental illness may be jailed inappropriately when mental health services are not accessible.

These data, not the old stereotypes and myths, show the benefits of providing comprehensive mental health coverage. I receive letters like Susan B.'s almost every day, reminding me that health, progress and success are possible when people have access to the right care. We need to include mental health fairly in health care reform, not just because it is right to end discrimination, but also because we now know it makes good sense.

Former First Lady Rosalynn Carter is chair of the Mental Health Task Force at The Carter Center in Atlanta, Ga.