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the number and type of providers seen for specific health problems, including mental illness.

Access and Availability of Services

Another aspect of the structure of health care concerns the availability of services. In each community there are limits on the availability of health services, but additional limits that are not present under indemnity insurance plans are likely to be imposed by managed care plans. Even though managed care plans control the availability of physician services, they provide 24-hour access and have financial incentives to provide accessible urgent care during off hours instead of having enrollees go to hospital emergency rooms (Gold et al., 1995a). A study of Medicare beneficiaries found them to be more satisfied with waiting times for an appointment under the managed care system than under the FFS system (Rossiter et al., 1989); however, these results were not specific to mental health care services. This leads to the following hypothesis:

Hypothesis 1B: Delays in receiving nonurgent care will be less in the managed care system than in the indemnity covered care system; urgent care will be more accessible in the managed care system.

Access and Unmet Need

Important differences exist between indemnity insurance and managed care plans in the use of coverage limits and out-of-pocket payments to control utilization and costs. Indemnity insurance coverage has relied on limiting coverage and imposing significant deductibles and coinsurance to reduce utilization and costs. The effects of deductibles and coinsurance were evaluated in the RAND Corporation's Health Insurance Experiment in the 1970s (Manning et al., 1986). The study found that persons were less likely to seek treatment when faced with significant out-of-pocket payments, but when treatment was sought, the pattern of treatment did not substantially differ by level of deductible or coinsurance (Keeler and Rolph, 1988; Keeler et al., 1986). This was found for both mental and somatic disorders.

In contrast, HMOs and other managed care organizations offer comprehensive coverage (except for specialty mental health services) and impose few or no deductibles and small or no copayments. When there are higher copayments for mental health care, these have comparable effects on reducing utilization (Simon et al., 1994). With the implementation of a managed behavioral health care carve-



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