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By Anne Scheetz

How would a single-payer health care system provide for the care of severe mental illness? Ilene Flannery Wells posed this question to us as part of her ongoing crusade to spare other people with severe mental illness, and their families, the suffering endured by her twin brother Paul in the years before his death in 2008.

Wells published Paul’s story in Psychiatry Online in August of 2010. Paul lived with schizophrenia for some thirty years, and died of lung cancer at age 48. Only when he developed a serious illness that was not classified as a mental disorder did he obtain the care he needed in the setting that was appropriate for him.

Following his first psychotic episode at age 16, Paul spent time in a private and then in a state psychiatric hospital; then, after the state hospital in 1998 was stripped of resources and prepared to close, in a series of “independent” living situations. As his family noted, his ability to care for himself played no part in his assignment to a particular level of care. For example, while he was losing weight, begging neighbors for food and cigarettes, and failing to apply for food stamps, his care coordinator made plans to move him into a less supervised setting.

During the last year of his life, Paul’s lung cancer and two episodes of pneumonia permitted him to live in a nursing home where he was well cared for. Had his mental illness, rather than pneumonia and cancer, been used as the diagnosis justifying his stay, Wells tell us, the nursing home could have lost Medicaid funding for all of its patients. This disparity in access to care is due to the Institutes for Mental Diseases Exclusion that is part of federal Medicaid rules—one of the instances of discrimination against diseases classified as mental with which our health care payment system is riddled.*

The single-payer health care system we envision and work for will pay for mental health care on the same basis as all other care. All medically necessary services will be fully covered, for everyone.

Community based care, preventive care, and primary care will be the foundation of the system; but specialist, hospital, and institutional care will also be provided for those who need such services. We know that not all chronic diseases are preventable or curable, and that in fact everyone eventually dies of something.

We do not use the term “community care” as a euphemism for abandonment, as happens when institutions are closed without regard to whether all patients are able to live in the community, and without the necessary support services and alternative sources of care being already in place. Rather, we work for a system in which community based care for people with all kinds of disabilities includes case management services, personal assistant hours, and peer support, as well as, if it is necessary, medical care by nurses, doctors, and therapists, and transfer to other levels of care when it is needed.

The single-payer system we work for does not assign people to different sources of payment depending on income, pre-existing conditions, or any other characteristic.

Rather, we say, “Everybody in, nobody out!” and “One nation, one health plan!”

For more information on Ilene Wells’ crusade on behalf of people with mental illness and their families see www.paulslegacyproject.org.

*Many articles on inequities in access to mental health care are available on the web site of Physicians for a National Health Program: search for "mental health."

See also the following articles on this web site:

Why I Sat In: The Fight for Chicago's Mental Health Clinics

Illinois Insurers Avoid Covering Mental Illness

Anne Scheetz, MD, is a member of Physicians for a National Health Program and the Illinois Single-Payer Coalition.