When presidential press secretary James Brady suffered brain injury from a gunshot wound during the 1981 attempt on President Reagan's life, he was assured of high-intensity acute and long-term rehabilitative care. How many of the rest of us can be so assured?

Today, several million Americans must cope with the aftermath of a traumatic brain injury, and each year, a half million more are added. These injuries cost society a staggering $4 billion annually. The personal cost, in terms of devasted lives and human suffering, is incalculable.

Victims of brain injury suffer a wide range of problems. In addition to physical disability, which may be quite profound, many suffer the loss of memory and reasoning ability, develop difficulties with language, and develop emotional and behavioral problems. This constellation of problems in the majority of severe cases renders victims unemployable and incapable of independent living. That places great stress on their families.

Any health care system designed to care for these patients must anticipate a prolonged period of treatment if it is to help patients become functional, achieve the best quality of life, and yet be cost-effective.

Such a system of rehabilitative care has been recommended by the National Head Injury Foundation (NHIF), but for most head-injured Americans, it remains an unrealized ideal.

Implementation of this system has been hamstrung by short-sighted policy decisions of some major third-party health insurers and government medical assistance programs. Instead of a comprehensive system, these policies have created a two-tiered health care system that provides services to the comprehensively insured and the wealthy, but abandons those who lack enough cash or coverage .

The idealized system would establish four levels of care: acute (normal hospital) care, including early rehabilitation services; inpatient care at brain injury rehabilitation centers; continuing outpatient care, and sustaining care. Each level would cost less than current services.

In the acute care setting, early rehabilitation intervention is frequently overlooked, even though it can reduce the total length (and cost) of in-hospital care.

There are few inpatient brain injury rehabilitation centers. Although more expensive than a regular hospital, they ultimately save money by speeding up the rate of recovery. The amount of time a patient spends at this level, however, depends on the availability of the next level of care, continuing outpatient services.

Outpatient services can save a large amount of money, but this level of care is most frequently denied coverage by third-party payers. Despite this lack of support, a variety of innovative programs have nonetheless been developed.

Day treatment programs, for example, can slash the cost of inpatient services by half. Day treatment provides the same intensive, day-long rehabilitation services that are offered inpatients, but the patient lives at home. There are also programs designed to treat patients at home, which may also permit family members to be employed rather than spending all their time as caretakers.

In some cases, patients can be rehabilitated enough to go back to regular jobs. In others, rehabilitation prepares them for jobs in sheltered settings. These improvements not only increase patients' sense of self-worth but allow them to contribute productively to society again.

This system of rehabilitative care provides for maximal individual care at minimal cost. By returning some patients to the productive workforce, reducing the level of dependence of others, and improving the quality of life for all, the system would save money while improving current levels of service.

Unfortunately, this philosophy is not shared by many major third-party insurers and government agencies, which operate from the unenlightened and inaccurate perspective that the cheapest method of rehabilitation is no rehabilitation.

In the state of Pennsylvania, for example, even inpatient care is compromised. Health maintenance organizations in most cases pay only for one or two months of inpatient rehabilitation services and for minimal follow-up services at best.

The medical assistance program puts constant pressure on rehabilitation facilities to discharge patients. And, since there are caps on the amount of reimbursement paid, facilities often wind up losing money whenever they provide rehabilitation services to medical assistance clients. To top it off, medical assistance will not pay for outpatient services at all, including day treatment programs that would reduce costs by half, and neither will medical assistance pay for comprehensive residential or community programs.

Interestingly, some of the more exclusive private insurance companies, especially those providing no-fault automobile insurance, actively seek out comprehensive rehabilitation services based on this model. They are convinced, on the basis of years of experience, of the long-term savings this model offers.

There is, then, a double standard for brain injury rehabilitation in this country. The wealthy, well-placed, and those with the best private insurance, have access to an ideal, comprehensive system of care. The poor, those on medical assistance, and patrons of some of the larger health care insurers, don't have access to this system. Paradoxically, the lack of access to a comprehensive system costs these companies and the government (ultimately, the taxpayer) more, in longer and more expensive hospital care, than the cost of providing comprehensive care.