Mental Fairness

Tera Michael could be a powerful cheerleader for health-care reform;
after all, universal health insurance might give her
family—including her husband and their two children—an
opportunity to rise out of the debt caused by her family’s health
issues.

Michael, however, isn’t ready to rally for reform. She says her
experiences give her little faith in politicians and their plans to fix
the health-care system she’s gotten to know too well.

In 2004, Michael weighed almost 300 pounds and had gastric-bypass
surgery to help her lose weight, but the surgery didn’t work properly,
and left her unable to fully digest food. After several surgeries to
repair the damage, eating certain solid foods remains a problem.

On top of her own health problems, Michael and her family have to
cope with their 15-year-old daughter, Tondra, and her bipolar disorder,
which causes extreme emotional highs and lows. The high school student
has been hospitalized three times in the last three years, usually
after threatening to harm herself and/or others.

“I just don’t know what to think,” Michael says about health-care
reform. “I’m not sure what to trust right now. I hope that they just
don’t forget about mental health.”

Michael has tried to get assistance for her daughter through the
state-run Arizona Health Care Cost Containment System (AHCCCS), since
Tondra was first hospitalized three years ago. The family has insurance
through her husband’s job, but Blue Cross Blue Shield of Arizona limits
hours on mental-health services.

A recent hospitalization at Sonora Behavioral Health Hospital, from
March 31 through May 1, plus medications were covered by AHCCCS,
because Tondra was out of her home for more than 30 days. Financially,
it offered the family relief—and the visit gave the family hope
that Tondra would get better.

While hospitalized, Tondra was placed on the medication Seroquel XR,
a psychotropic medicine often prescribed to treat bipolar disorder. It
was the first medicine that has helped curb Tondra’s manic episodes,
and it’s continued to work.

When Tondra was hospitalized, her family was told the next step for
their daughter was a three month stay in a residential therapeutic
center, and transitional service when she returned home. But on May 1,
Michael received a call that her daughter was being discharged. The
family considered not picking her up—to force the hospital to
continue treating her—but they were told Tondra would be turned
over to Child Protective Services if they did leave her there. Hospital
staff told the family they could no longer offer services to Tondra,
but that AHCCCS was placing her with Pantano Behavioral Health, a
Tucson clinic that provides counseling and psychiatric services.

She was told someone from Pantano would meet the family to discuss
services. In the Sonora parking lot, the family met with a caseworker
that day to sign off on a plan that would include intensive therapy to
help Tondra transition back home.

“But that never happened,” Michael says, although Tondra does
participate in a regular anger-management therapy group at Pantano.

Pantano Behavioral Health clinical director Jon Reardon did not
return calls for comment.

Michael says AHCCCS provided prescriptions for 60 days. She and her
husband applied for continued AHCCCS help, but were denied based on his
income: Michael’s husband makes $39,000 a year. If the family lived at
or below poverty level, AHCCCS would help. Or if Tondra was like her
brother—diagnosed with a developmental disorder, like
autism—she would be able to receive AHCCCS, because care for
developmental disorders is covered, despite a family’s income.

Monica Coury, an AHCCCS public information officer, says AHCCCS is
following state and federal guidelines when making these decisions.

Coury recommended that the Michaels look into another state program,
KidsCare, which provides health insurance to uninsured kids. Michael
says they would have to take Tondra off her husband’s insurance plan
for 90 days to qualify. It’s a risk they are not sure they want to
take.

The family’s Blue Cross recently denied coverage for Tondra’s
Seroquel prescription. According to a letter Michael received, Blue
Cross says it won’t pay because the drug is not recommended by the
manufacturer for anyone younger than the age of 18.

Renée Hunt, a media assistant for Blue Cross, says the
company follows Federal Drug Administration guidelines, as well as
guidelines from drug manufacturers.

Out of pocket, the drug costs $658 a month.

“Right now, we don’t even have extra money after paying bills each
payday. How would we be able to afford this?” Michael asks.

On Thursday, Sept. 17, Michael and her daughter are slated to go
before an administrative judge in an appeal hearing. They hope the
judge will approve Tondra’s application for AHCCCS, despite the fact
that they do not meet income guidelines.

Michael has less than 10 days left of Seroquel for her daughter. The
only other hope they have is an appeal filed with Blue Cross to
reconsider its decision. Hunt says the company recommends appeals in
situations like this, especially if the patient can prove the
medication is working, although she wouldn’t comment specifically on
Michael’s case.

Michael says her daughter’s psychiatrist and pediatrician have sent
letters to Blue Cross saying that the medication is working. Besides
medical proof, Michael looks to school: Last year, her daughter was
suspended from school 30 times for behavior problems. This year, Tondra
has been sent to detention a few times for being tardy, but has not
been punished for behavior problems.

“It’s a big difference,” Michael says.

H. Clarke Romans, executive director of the National Alliance on
Mental Illness of Southern Arizona, says what the Michael family is
going through isn’t unusual. Those with mental illness face
discrimination across the board, but especially in insurance coverage,
Romans says.

“There’s a stigma attached to mental illness,” Romans says. “…
Families need to speak out, but it’s difficult when you feel as
isolated as people with mental illnesses and their families do. Until
legislators pay attention, we expect very little will change.”

This article appears in Sep 17-23, 2009.