Alice is a GS-2 clerk typist in her early 30s. She works hard and supports her two young children by herself. Sometimes, out of the blue, she hears voices telling her to harm herself or her children. When she hears the voices she runs into a clothes closet, where she hides from the evil demands.
Without insurance-subsidized psychiatric care, Alice would have to be hospitalized, but with the help of outpatient services, she can continue to work and stay home to take care of her family.
Some mornings, Roger would be so depressed he couldn't get out of bed. For nearly 10 years he tried masking his unhappiness with alcohol, which led to his discharge from the military where he had planned a career.
Insurance coverage at his new civil service job, however, allowed him to receive psychiatric help outside of a hospital. He has since sobered up, married, begun a family and no longer needs regular counseling.
For about 15 years, federal employes or dependents covered by Blue Cross/Blue Shield have been able to get help for emotional problems under the same payment terms as any other illness. Beginning Jan. 1, however, Blue Cross subscribers taking advantage of mental health benefits will find their reimbursements cut by 10 percent.
On the same date, premiums of all subscribers will increase 16 percent, and the annual deductible for supplemental benefits, which includes outpatient counseling, will jump to $150, an increase of 50 percent.
Negotiators of the new plan are defending the change as a way to finance much-desired improvements in dental care coverage, but some local psychiatrists see the change as a form of discrimination against the mentally ill. Dr. John J. McGrath, for one, is incensed. "They'll do it because the cost of covering psychiatric illness is rising," he said. "Over the last 10 years, out of every buck Blue Cross/Blue Shield spent, they paid seven cents for psychiatry. There's been no fraud, no rip-off. There's been extensive peer review.
"They're doing it because they want to make the plan more marketable. Mental illness is very expensive to get; that's why you get insurance. As you know, the mentally ill are already stigmatized, they want privacy, they don't talk out, they don't organize. And the unspoken message is, "We can take it out on the mentally ill because we can get away with it."
Spokesmen for both Blue Cross and the federal Office of Personnel Management, which negoiates on behalf of federal workers, agree that the plan was redesigned to finance dental services. But, they say , they did not intend to burden mental patients unfairly, either financially or psychologically.
"I really don't know what to say," said William Gilfillan, a contract compliance examiner with the Office of Personnel Management. "For the last several years we've been unable to add on or improve benefits because of increases in the premium, and for the last several years employes have requested dental coverage. So it's a tradeoff for actually a small group of people for many more people who will use the services."
Dr. James Collins, chairman of the psychiatry department at the Howard University College of Medicine, challenges that thinking.
"It maybe only one percent of the people who use the service, but you never know who that one percent is," he said. "Even here at Howard, we reimburse 50 percent (cost of treatment for employes), and still that's a lot of money for a lot of people. You've got to be well into the middle class to afford that.
"Then if you consider that we are treating primarily depression and substance abuse, you can see the population that is going to be adversely affected."
Of the 3 million federal employes in the nation, about half choose Blue Cross every year. Blue Cross is even more popular in the Washington area, with the 700,000 local subscribers comprising more than 10 times the number enrolled with its closest competitor, Aetna Life and Casualty. Blue Cross subscribers have received the most liberal benefits from any government-wide program available for mental and nervous disorders since Aetna lowered the amount of its reimbursement a few years ago.
Federal employes who elect Blue Cross/Blue Shield choose high- or low-option, which offers more coverage at greater cost. Under high-option coverage, subscribers pay $26.87 biweekly, which will increase to $30.50 Jan. 1.
Under the present plan, patients see the doctor of their choice, submit their claims and after payment of the first $100, get back 80 percent under high option, and 75 percent under low option, regardless of the illness. As of Jan. 1, high-option subscribers will get back only 70 percent after payment of the first $150, and low-option subscribers will receive only 60 percent.
Ray Freson, public relations manager for the Blue Cross/Blue Shield metropolitan office, said, "The magnitude of the cutback wasn't that great; it wasn't a crippling reduction and there's still more coverage in Blue Cross than any other program."
Besides, he said, "My impression is that the more sophisticated people tend to use the care rather than the lower-middle-class people."
According to the Washington Psychiatric Society, the average cost of one hour of individual counseling locally is $50, with the severely overburdened Area Mental Health Centers offering the cheapest care at $37 per hour.
Under the new plan, the cost to the patient will increase from $12 to $18 per visit. Doctors expect the change to significantly dampen the willingness of patients to seek long-term treatment, which may require form one to three visits a week at the outset.
Doctors also believe the new plan unfairly penalizes patients for seeking outpatient care. Hospitalization benefits will remain the same, and coverage for inpatient treatment for alcoholism has been increased from three to 28 days.
"This drives people into hospitals," McGrath said, "and the whole effort of the (psychiatric) profession in the last recent years has been toward deinstitutionalization, of keeping people with their families."
The primary users of the mental health services among federal employes tend to be workers in the five lowest-grade classifications, for whom the cost increase will be the most devastating.
A study first published in May 1979, revised in March, and directed by Dr. Steven Sharfstein of the National Institute of Mental Health, demonstrated that workers in the five lowest grade levels use the insurance for mental health benefits more frequently and for more costly services than do any category of upper-level employes.
Moreover, the study found, lower-grade workers tend to use the benefits when they are ill themselves, whereas upper-grade workers use the benefits for their dependents. Thus, hospitalization in lieu of affordable outpatient care affects the lower-income federal worker's entire family, since the beneficiary is more often the wage earner. The worker's ability to stay in the labor force may depend on the availbility of out-patient care.
"What is startling, you know, is that this is the federal government," McGrath said. "And Rosalynn Carter is the most effective champion for the mentally ill we've ever had anywhere near the White House, and here is the federal government discriminating against the mentally ill."
Negoiations for the yearly plan are conducted between the insurance companies and the Office of Personnel Management from April to September each year. The plans are presented to workers in the annual "open season," from mid-November to mid-December, during which they may choose coverage for the coming year, and the negotiation process leaves little room for appeal this year.
Doctors, insurers and workers' represntatives agree that the affected party is probably not political enough to cause a public outcry, but, said McGrath, "This is a group for whom it just doesn't make sense to say that 10 pecent isn't all that much. What's going to happen is that people are going to put off illness for another year."