MENTAL-HEALTH-SERVICES IN THE CONTEXT OF HEALTH-INSURANCE REFORM

Health care reform offers opportunities to improve the care of persons with serious mental illness, but it also can lead to the disruption o f innovative systems of care that have been developed in recent years through Medicaid and other public programs. The care of mentally ill p ersons must be organized to maximize possible trade-offs between inpat ient and other community services in a way that will promote function and satisfactory adjustment. An indemnity approach emphasizes controls on demand; instead, better design of supply-side approaches is requir ed, using incentives to integrate services through case management and other methods. Considerable capacity development is needed to integra te long-term care appropriately into the mainstream, but serious barri ers include control of risk selection and the difficulties of fairly a djusting capitation rates for high-utilization patients. Issues in men tal health care are paradigmatic of many other areas of medical care a nd reflect changing family and community organizations and new challen ges in care and rehabilitation.