For years, I have been writing in various forms about the impending implosion of the American health care system while predicting that real health care reform was just around the corner. Regrettably, those forecasts have been about as accurate as those made by the infamous UFO Doomsday Cult chronicled in Festinger’s early cognitive dissonance writings.
This, however, is not to say that psychology has not benefitted legislatively in 2008. With the passage of the historic mental health parity bill and the Medicare fee restoration victories, substantial gains certainly have been made recently. It is the larger health care system in general, that remains comatose, and on life support, as it has been for more than a decade.
But, the “times they are a changing.” The election of Barack Obama, whose campaign identified major health care reform as one of it key priorities, the expanded Democratic majorities in both houses of Congress, and the nearly universal public desire for change, collectively make the prospect for finally implementing substantial health care reform very high.
Enthusiasm about reform, however, must be tempered by the cold reality that the federal coffers have been drained by the Iraq war with no immediate end in sight, and by an economy that is in a state of free fall.
The real question boils down to whether government leaders who appear ready to comprehensively tackle the health care issue for the first time in 15 years, with an economy at its worst point since the Great Depression, will really step up and devote the attention and resources that are required to overhaul the U.S. health care delivery system?
Call me a perennial optimist, but I am very excited about the historic opportunity we have at the moment. The public wants it. Our leaders have called for it. And while everyone concurs that the nation’s economic condition demands critical attention, our economic problems make reform of the health care system even more urgent because of their impact on: people’s health and well-being, the increasing extent to which people can no longer afford needed care, and the inability of U.S. businesses to compete due to the burden of providing ever more expensive health benefits to their employees. Further, economic insecurity and health care insecurity have become intertwined, and we cannot afford to address one to the exclusion of the other.
Rahm Emanuel, President-elect Obama’s new Chief of Staff, may have said it best from my perspective, when he observed, “You never want a serious crisis to go to waste.“ He told the Wall Street Journal, “Things that we had postponed for too long, that were long-term, are now immediate and must be dealt with. This crisis provides the opportunity for us to do things that you could not do before.” Emanuel knows well the issues involved with health care reform from both having served as a political and policy aide in Bill Clinton’s White House, and more recently as a member of the Health Subcommittee of the House Ways and Means Committee.
“The idea of a federal, single-payer system patterned on those in Europe and Canada, long a dream of the political left, appears to now be virtually off the table. Rejected as well is the traditionally conservative concept, championed by Senator John McCain during the presidential campaign, of reforming health care mainly by giving incentives for more Americans to buy insurance on their own.”
The theme of “opportunity provided by the crisis” will likely be amplified as thousands of additional Americans lose jobs in the recession that lies ahead, they also will lose their employer-provided health insurance and swell the ranks of the nation’s uninsured. That will add a bit of rocket fuel to the Obama call for universal health coverage.
The good news is that the prospect of bold government action appears to be also accepted now among the key players across the ideological and political spectrum, including those who opposed the idea in the 1990s. After decades of failed efforts to reshape the nation’s health care system, a consensus appears to be emerging in Washington about how to achieve the elusive goal of providing health insurance to all Americans.
The answer agreed upon by most leading stakeholders (businesses, hospitals, provider groups, labor unions and insurance companies) — as well as senior lawmakers on Capitol Hill and members of the new Obama administration — is unprecedented government intervention to create a system of universal protection.
At the same time, those groups, which span the ideological and political spectrum, largely have agreed to preserve the employer-based system through which most Americans get their health insurance.
The idea of a federal, single-payer system patterned on those in Europe and Canada, long a dream of the political left, appears to now be virtually off the table. Rejected as well is the traditionally conservative concept, championed by Senator John McCain during the presidential campaign, of reforming health care mainly by giving incentives for more Americans to buy insurance on their own.
There also is a widespread understanding that any expansion of coverage must be accompanied by aggressive efforts to bring down costs and reward quality care. And key players in the health care debate increasingly back a massive investment of taxpayer money for health care reform despite the burgeoning budget deficits.
Beyond those areas of basic agreement, the details of what would be one of the most momentous changes in domestic policy since World War II remain vague. And, herein lies the proverbial rub.
As a presidential candidate, Barack Obama embraced both expanded insurance coverage and preservation of the jobcentered system, but since he won the White House he has provided few specifics about his plans once he takes office.
Disagreements over specifics could again lead to the kind of stalemate that has caused the health care reform gridlock of the past 15 years. Even the most gung ho advocates of sweeping reform concede that difficult negotiations lie ahead.
In this context, I feel compelled to underscore the overwhelming significance of having finally enacted the mental health parity legislation last Fall. We all celebrated parity’s passage which had required ten long years of arduous effort. What has not been acknowledged, however, is how crucial it is to have parity in place during the upcoming debates about the role of psychology in any new health care system.
Imagine what a diminished position psychology would be in if mental health was still treated as a second class citizen in the health care firmament as it was prior to parity’s passage. Now, since the advent of the parity bill, mental health is on an equal footing with physical health in every venue including all legislative debates.
In the coming months, despite the good will of all stakeholders mentioned above, there will be many issues to resolve before a health care package can come to fruition. One will be whether the roughly 46 million uninsured people in the U.S. will be pushed to buy private coverage or will be enrolled in a government insurance program, as some consumer groups want.
Another point of contention will be that hospitals and providers fear another public program would reduce what they are paid, as Medicare and Medicaid have done. Another is that insurers worry they could lose customers to the government.
A major issue to be resolved is how the government will control costs and set standards of care. Some proposals that raise the unpopular prospect of federal regulators dictating which doctors Americans can see and what drugs they can take will have to be dealt with. Unfortunately, there is little question that once policy makers get into the details, the consensus of all the disparate groups is likely to vanish pretty quickly.
There is one inescapable fact which simply stated is: increasing access for the uninsured is not going to come cheap. Can our economy stand much further deficit spending?
Attempts to better manage costs have not worked. Managed care rose and fell in the mid-nineties, but market-based solutions continued to dominate the health policy discussion, particularly in Washington. The structuring of the Medicare drug benefit around competition between private plans, each offering a different benefit at a different price, was a powerful illustration not just of the dominance of interest groups but of the political aversion to government regulations of health care that until recently held sway.
With the financial meltdown and the victory by Democrats who favor a more interventionist role for government, there is renewed interest in regulation and government oversight to make the marketplace work more effectively and safeguard consumers, including in health. Virtually all the major health reform proposals now on the table — including those from President-elect Barack Obama and Senate Finance Chair Max Baucus — contain some regulatory features. Most often discussed are requirements that health insurers take all comers without surcharges for people with preexisting conditions, and limits on the amounts insurance companies can charge for administration and profit. These proposals do not go nearly as far as the Clinton health reform plan did, which also proposed regulation of health insurance premium increases and underlying hospital charges and doctors’ fees, but they represent a marked change from the recent anti-regulatory mood in Washington.
Other currently popular ideas have a regulatory flavor as well: establishing a national comparative effectiveness research institute, a favorite of Senator Baucus, to ultimately provide guidance on what to pay for and what not to (a variation on the familiar evidence-based practice theme that has been floating around psychology forums for years); requirements that providers adopt standards for IT which both houses of Congress are currently working to develop; and giving the Secretary of HHS power to negotiate drug prices under Medicare
The regulatory components of health reform may have staying power because regulation does not require federal expenditures and will be popular with the public. They strike right at the concerns the public has about costs, which has propelled health care forward, but don’t bring the high price tag policymakers will have to struggle with in order to pay for coverage expansions. They do, however, require taking on interest groups who will be affected by regulation, particularly insurance and drug companies.
I think it is fair to say that today many of the key players in the debate see the importance of preserving elements of the current health care system that many Americans say they like. And, there is a growing understanding that you have to give people choice and you can’t take away what they have. Any proposal would be well advised to avoid threatening the coverage that people already have.
This is a challenging time for our country, but it is also a time of opportunity. And just as the collective effort of American voters made history, psychology’s collective voices can help ensure that our leaders make meaningful mental health reform a key ingredient in any overall health reform package. As we continue our work to make mental health a national priority and expand access to care, we hope you will continue helping us in these vital advocacy efforts. We recognize that in these tough economic times finances are tight. Please be as generous as you can be in your contributions to AAP/PLAN. In a sense, the real work will NOW begin for mental health in this new period of health care reform.