Each year, an estimated 56 million Americans - one in five people - experience diagnosable mental disorders. In addition, 4 of the 10 leading causes of disability in the U.S. are considered mental disorders, including depression, bipolar disorder, schizophrenia, and obsessive-compulsive disorder.

Among those who suffer from mental illness, only one in four adults and one in five children actually receives some form of care. Left untreated, mental illness can cause its victims to lose their jobs and happiness, and often leads to crime, poverty and homelessness.

Even more than other areas of health and medicine, the mental health field is plagued by disparities in the availability of and access to its services. While these disparities are often attributed to race, age and gender, the most important factor that determines whether or not a person receives care is his or her financial status.

For those who are diagnosed as mentally ill and receive care, most treatments fall into one or both of two general categories, psychosocial (therapy) and pharmacological (medication). For those who are mentally ill and do not receive care, the suicide rate is 90 percent.

The U.S. mental health care system consists of a complex patchwork of public and private mental health services - often referred to as a de facto mental health system. The four sectors of the system are:

• The specialty services sector, which consists of services provided by specialized mental health professionals (e.g., psychologists, psychiatric nurses, psychiatrists and psychiatric social workers).
• The general medical/primary care sector, which consists of non-specialized health care professionals (e.g., family physicians, nurse practitioners, internists, pediatricians, etc.).
• The human services sector, which consists of social welfare, criminal justice, educational, religious and charitable services.
• The voluntary support network, which consists of self-help groups and organizations that are devoted to issues that extend beyond formal treatment, including education, communication, and support.

Federal action to improve mental health services in any of these sectors has been limited. In recent years, very little legislation has been passed with the intention of protecting the mentally ill. Although the Americans with Disabilities Act (ADA) arguably provides protection by prohibiting discrimination against the disabled, Congress and the courts have resisted efforts to interpret ADA as requiring mental health services.

Medicaid provides health and mental health care coverage to 41 million low-income individuals. It is also a very important source of revenue for public mental health systems. Individuals with mental illnesses--both those on Medicaid and those with private coverage--tend to be frequent users of both health services and disability benefits.

For several years, analysts have recognized a growing need for accountability and effective management of public mental health systems. During that same period, the use of managed care in public mental health systems has increased. While several states are privatizing their mental health systems through contracts with corporations, others are adopting the techniques of managed care in ways that are specific to their existing systems.

In 1997, total spending on mental health care in the U.S., including both health care costs and lost productivity, came to more than $170 billion. Of this amount:

• " Direct costs totaled $70 billion - about 8 percent of total U.S. health care expenditures.
• " This included $18 billion in spending for Alzheimer's disease and $13 billion for substance abuse treatment.
• " Indirect costs were estimated at $79 billion. (Economists calculate indirect costs by assessing the costs of lost productivity at the workplace, school, and home due to disability).

Medicaid funds nearly half of all expenditures for public-sector community mental health care. In 1998, over $14 billion in Medicaid spending (around 8 percent of total Medicaid spending) went to public mental health services.

As Stefan Bauschard points out in his public health services essay, the mental health topic revolves around three basic issues:

• Should mental health services be provided?
• Who should be the provider?
• How should services be provided?

Most Affirmative cases on the topic will probably focus on an issue stemming from one of these three questions.

By and large, mental illness is treated as a separate class of illness in the U.S. health care system. Most insurance plans set limits on mental health coverage that are more restrictive than those imposed on other medical illnesses. The current public policy debate in mental health is therefore focused primarily on the issue of "mental health parity."

At present, there are parity laws in 34 states, but no federal law. This means that there are no federal mandates on private employers or insurance companies to treat mental and physical impairments in the same way. Many cases may therefore be devoted to achieving "parity" or to increasing access in other ways, especially among disadvantaged groups.

Access cases may emphasize government-oriented or private sector solutions. The most popular cases will probably include:

• Expanding insurance coverage for mental health services.
• Increasing government programs and services for the homeless and ethnic minorities.
• Increasing prescription coverage for mental illness medications.
• Expanding services in prisons and jails.

Many affirmative plans may also seek to solve access problems through preventive strategies, including mental health education, increased spending on diagnosis techniques and suicide prevention. Non-access cases could include issues related to:

• Increasing pharmacological research and development
• Addressing problems of involuntary commitment
• Addressing problems of restraint and seclusion
• Privacy of medical records
• Intervention
• Criticisms of psychiatry

Negative arguments could include cost escalation, privacy concerns, stigmatization, public inefficiency, solvency issues, government intrusion and federalism.

Public Health Services and Mental Health Care (Stefan Bauschard, Paradigm)

NFHS Public Health Topic Paper (Sandy Patrick)