Vanderbilt Law Review


Wayne E. Ramage

First Page



In all the furor over the provision of health care in the United States-especially over who will pay for the skyrocketing costs of medical treatment-one class of patient appears to have been overlooked: the mentally ill. This oversight is not new; Anglo-American society historically has viewed the mentally ill as outsiders. In England, for example, inmates at the infamous "Bedlam" hospital for the insane often were displayed for the amusement of the paying public.' Society's disdain of the mentally ill still exists and has led to public neglect of these unfortunates, especially in the provision of mental health care.

Since the process of deinstitutionalization first began, the law has been involved intimately with mental illness. In the 1960s scholars criticized the intellectual foundations of psychiatry, and numerous law- suits sought to abolish involuntary commitment.' These early critics primarily wanted to protect the right to refuse treatment; specific targets were the somatic treatments for major mental illnesses, particularly psychosurgery, electroconvulsive therapy, and psychoactive drugs. Some advocates for the mentally ill continue to fight for freedom from treatment, while others have adopted a more cautious approach.

As with health care in general one of the most difficult mental health care questions facing American society in the 1990s is: Who will fund the rapidly increasing cost of care? This Note examines the role of the private sector in funding emergency and longer-term care for the mentally ill. Part II describes the magnitude of the mental health problem in the United States and documents the failure of public and private insurance programs to fund mental health care adequately. Part III examines indirect funding by primary health care providers and suggests that Congress expand existing federal law to require hospitals and physicians to provide emergency care to the mentally ill who present a danger to themselves or others. Part IV examines direct funding by private insurance, focusing on the continuing validity of mental illness benefits-limitation clauses under common and federal law. Part V concludes that any alternative system likely will perpetuate the inadequate level of mental health care currently provided, unless the stigma associated with mental illness can be overcome by special recognition of the seriousness and treatability of mental illness.