Mental Fairness

Though the Michael family is insured, they can't afford the help that an ill daughter needs

Tera and Mark Michael have health insurance, but it isn't enough to care for their ill daughter.

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."

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