As you recall, Presidential candidate Obama regarded health care reform as a top priority, positioning it among his top three agenda items last year. After the election, unlike most presidents who enter office, Obama not only has to tackle the agenda on which he campaigned, but a second agenda forced upon him by the events that have transpired as he entered the White House. In psychology, I believe we refer to this having “been dealt the mother of all bad hands.” From the stimulus bill, to trying to save the auto industry, to North Korea, Iran and the Middle East; Obama has had his hands full. Even worse, he is currently holding a handful of cards no layman, never mind a president, would ever want to be holding.
Despite this bleak situation which impacts everything and everybody these days both at home and abroad, the President continues to advocate vigorously for health care reform and the Democrats vow that this matter will be acted upon before the upcoming August recess.
Mark Twain once said that anyone who appreciates the law or sausage should never watch either being made. Over the coming months, I believe Twain’s admonition will be especially prescient, and the squeamish among us are advised not to watch as health care reform legislation unfolds. A highly unstable economy, a jittery contingent of Democrats just elected in red states, a highly resistant GOP, and a large cohort of liberals who feel invulnerable, all combine to make for some big-time conflict ahead, specifically with regard to health care reform.
This is not new, as most of us have learned. Health care change is an enormous challenge even in the best of times. First Teddy Roosevelt examined it. Then FDR proposed it. Harry Truman introduced it. None succeeded. LBJ wanted to cover all Americans, but settled for Medicare and Medicaid. Teddy Kennedy and others have been attempting to create a health care system ever since, and have not been able to break through the sizable barriers that have stood in the way.
As I’ve written previously, the Clintons in 1993 and 1994 were the last to fail and it was this failure that removed serious reform from the table for the past 15 years. But that was then, and this in now. Obama, a great student of history, has learned from the mistakes which scuttled Clinton’s Natioal Health Security Act. Much of what Obama learned has to do, not with substance, but with process, as we psychologists are often wont to say. Thus far, he has been letting Congress take the lead which is the direct antithesis of how the Clinton’s formulated their plan which primarily occurred in quasi-secrecy.
The Clintons drew up their bill behind closed doors and then told Congress to enact it. It doesn’t take a PhD in psychology to recognize that the US Congress has its fair share of egotistical legislators who don’t take kindly to being told what to do. As we go to press (early June), news reports indicate that Obama now recognizes that he must exert greater control over the health care debate and is preparing an intense push for legislation that will include speeches, town-hall meetings, and much deeper engagement with lawmakers.
Obama also has kept his eye on the ball with regard to his liberal base of supporters. This base has expressed substantial discomfort with Obama for not promoting popular issues favored by the left. So far he’s been resistant to the “don’t ask, don’t tell” kind of splitting that foiled Clinton early in his term. He has studiously avoided incorporating the dream element of the far left in his proposals to this point, the single-payer option. He understands that doing so would eliminate any support whatsoever from conservatives and even some moderates in Congress.
Obama also has, true to his word, reached out to traditional opponents of reform like the insurance industry and healthcare CEOs. Hearing their positive expressions of support at this point in the debate, however, doesn’t mean they can be counted on. But it does mean they recognize this health care reform train is rolling down the track and they want to be seated at the table in the Club Car. That is miles away from the reform climate which existed in 1994.
The White House has made clear that they want to insure about 30 million more people than are currently covered by insurance (this would leave 17 million uninsured). Adding this large number to the already insured would theoretically reduce costs due to the increased competition created by adding a government/public insurance option, and also would end denials of coverage based on preexisting illnesses and expense involved.
Sounds good on paper doesn’t it. Hold on though, there are two central areas of huge contention that are very critical to the success of substantive reform. The first, it should be no surprise, is cost. The Congressional Budget Office in May calculated the cost to be $1 trillion over 10 years. Where does all this cash come from? There’s only one way to raise this much revenue, and you guessed it, it’s called TAXES. A hot issue on Capitol Hill these days is deeply examining the employer-sponsored insurance program which covers the largest number of lives in the US. These benefits are untaxed and are a byproduct of businesses evading wage controls during World War II. So the talk on Capitol Hill revolves around what impact would occur if these benefits were taxed.
Taxing all employer-based plans would bring in the largest amount of revenue of all ideas being considered, about $2 trillion over the 10 year period. This would of course, create some major political consequences. So, the focus has turned to exploring options for these kinds of taxes. Should only the most elegant plans be taxed? Elegant ones are those that are the most thorough and expensive plans. Or, should plans be taxed only on those individuals making over the magic number, $250,000, which was promised by Obama during the campaign.
At this point, Congressional waters are incredibly turbulent. Charlie Rangel, whose Ways and Means Committee will play a key role on the revenue side, has weighed in and said he is dead set against all this. In late May some top Republicans rolled out their own plan which, quite surprisingly, would tax every employer-sponsored plan. These taxes would be compensated for with tax credits for the purchase of plans from the private market, a clear concession to the Republican’s friend in the insurance industry.
After cost, the second major obstacle to health care reform is the “public” option, which was a cardinal feature of Obama’s campaign proposal. A public insurance provider option is viewed as a way to force competition on the private plans. The model for this put forward by Obama and the left is a Medicare-style public option. There is tremendous opposition to this option by the right, who see it as the first step to socializing health care under the evils of a “government-run” health system. Senator Kent Conrad (D-ND), a former AAP Black Tie Honoree, has worked on a compromise proposal. His plan would be to set up cooperatives for insurance similar to those that deliver electricity to many rural parts of the country. SenatorMax Baucus (D-MT) apparently likes Conrad’s proposal and said in late May that it well could form the basis for a bipartisan compromise on his Senate Finance Committee which is a key player in the development of health care legislation. Senator Schumer (D-NY) has begun to discuss another compromise of sorts which essentially would force the public option to pay for itself without the benefit of government revenues or taxes, relying instead on premiums and co-payments for sustenance.
There is no shortage of ideas on this matter as evidenced by only a few of the proposals currently floating around. In fact, Chairman of the Senate Health, Education, Labor and Pensions Committee (HELP) just released the landmark “Affordable Health Choices Act.” This bill incorporates a robust array of benefits most psychologists would be very satisfied with, from clear inclusion of mental health and substance abuse treatments in the underlying structure of the bill, to inclusion of psychologists in discussions of integrated care, as well as involvement of mental health in matters dealing with prevention. There is a high probability that Kennedy’s bill will be the high water mark for psychology in the various bills offered on health care reform. The next bills we see are likely to be less generous in their treatment of MH and SA provisions. Our APA Practice Organization lobbyists will continue to vigorously press for appropriate treatment of mental health and psychological services in all bills that are released.
Obviously, the House and the Senate are working on these issues right now. Look for hearings over the summer and a possible final bill around September.Will such a bill be perfect? No. But, given the enormously complex issues that must be resolved, as discussed above, is no minor legislative task. Health care reform, if done correctly, will be monumental. Given the country’s recent shift leftward, the momentum appears to be in place for this to finally happen. Historically, a large government benefit once granted is never taken away. If a significant healthcare reform bill is enacted, it has the power to alter the country’s way of thinking for generations. The right is very cognizant of this tendency and will resist the leftward shift with a vengeance. That, in addition to the fact that what is at stake in health care involves a more than 2 trillion dollar a year industry, are at the core of the current battle.
Last year, AAP and the APA Practice Organization helped lead the fight to pass mental health parity and end decades of insurance discrimination. Now we are moving beyond parity and attempting to make mental health/psychology a central part of health care reform.We have to keep mental health on the national agenda.We want to make sure those whose lives are affected byWashington’s decisions, both our patients and ourselves as providers of services to those with mental disorders, are represented in health care reform.
Through our political advocacy work on Capitol Hill, AAP is helping to win recognition that mental health is the stepping stone to healthy and productive lives, workplaces and communities. To keep up this intense work, it takes resources and people. Please make as generous a contribution as you can make at this time to AAP and AAP/PLAN. As important, recruit a colleague to join you in supporting AAP and AAP/PLAN.We need for all psychologists to help us increase our presence on Capitol Hill.