cannot match. Further, informal supports are a major source of emotional and other support. A nationally representative study of individuals aged 70 or older found that those treated for cancer received an average of 10 hours of help in activities of daily living from informal caregivers per week, at an estimated annual cost (in 1998 dollars) of $1,200 per patient and just over one $1 billion nationally. The economic worth of caregiving is actually likely higher, as these estimates do not include costs of caring for patients younger than 70, those residing in a nursing home, and those not being treated for their cancer. Estimates also do not include a number of other costs, including those of addressing limitations not experienced by individuals “most of the time” (Hayman et al., 2001). If informal supports were unable to continue providing these services, the costs to patients and to the health care system would be sizable. Yet despite the widely accepted importance of supporting caregivers in carrying out this role, as discussed in Chapter 3, how best to accomplish this is a question not yet well answered by research.

Policies Constraining Service Accessibility

A final observation on the availability of services as illustrated in Table 6-3 is the extent to which “with limits” or “coverage depends on policy” describes the availability of mental health care. The lack of health insurance generally, greater limits placed on mental health benefits, and restrictions on access to some mental health providers can be a serious impediment to receipt of mental health services.

Absent or Inadequate Insurance Coverage

An estimated 44.8 million Americans (15.3 percent of the population) were without health insurance in 2005 (U.S. Census Bureau, 2007), and many more have only modest insurance coverage, coupled with an income level that limits their ability to pay health care costs out of pocket. The adverse effects of no or inadequate insurance are well documented and include poorer health, delayed treatment, and worse outcomes of medical treatment for people with cancer as well as other diseases (IOM, 2002). Even for those who are fully insured, coverage for mental health services is frequently more limited than that for other medical conditions. In 2002, 2 percent of workers with employer-sponsored health insurance did not have a mental health benefit. Of the 98 percent that had coverage, 74 percent had limits on the number of outpatient visits they could make in a year, and 22 percent had to pay a higher copayment for a mental health visit than for a general medical visit (Barry et al., 2003). Medicare similarly requires higher

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