AAP Newsletters

There has never been a time in the history of psy-chology’s political action program (38 years) that the role of the Association for the Advancement of Psychology (AAP) has been more critical than the present time. The unprecedented political turmoil in Washington combined with almost four years of a fal-tering US economy, have thrust psychology services into imminent danger of being chopped by the federal budget ax. At the August AAP Century Club Reception, this year’s honoree, Senator Sherrod Brown, amplified this point when he expressed his fear that psychology’s “valuable services could face cuts in the upcoming federal deficit reduction negotiations.”

Some psychologists (not AAP members, of course) may think that their practices are immune from such threats because, for instance, they don’t provide Medicare services. I’d like to tell them, think again. Medicare benefits and all federal programs provide the standard by which all private insurance companies determine the mental health benefit packages they themselves will offer to providers. All psychologists who participate in any sort of third party reimburse-ment are affected by this threat.

Summer seemed to zip right by this year and for much of it, we were bombarded by the incessant media cov-erage of the debt ceiling crisis in Congress. A short term fix was finally agreed upon in the eleventh hour, averting financial armageddon, as you know. The com-promise agreement included the creation of a new 12 member “Super Committee,” a congressional debt reduction commission which is tasked with figuring out a way to cut a whopping $1.5 trillion in federal spending by November.

Given the composition of the Super Committee (6 Dems and 6 Reps), accomplishing this goal is, in short, a near impossibility given the current hardline partisan climate extant in DC. Republicans do not want tax rates to go up and will oppose any deal that includes tax hikes. Democrats are loathe to touch any aspect of entitlement spending that could impact recipients. If the group cannot work out a compromise between the competing partisan needs of each side, mandatory spending cuts will be triggered in areas both parties hold sacred, entitlement programs and military spending

It is no secret that he American public is fed up with the inability of our elected representatives to address the most pressing problems of our times due to unprecedented partisan recalcitrance. Polls show Americans not only want to throw the bums out, a view voters often express, but now they even want to eject their own representative. This change represents a colossal shift in voter attitudes. Heretofore, voters typically viewed their own elected officials as tolerable, while believing that most other elected officials were the culprits responsible for all the problems in Washington. That was then, and this is NOW. A Pew Research Center survey released August 25th said 86% of Americans were “frustrated or angry” with the federal government. Republican leaders’ approval ratings dropped to 22%, with Democrats not much better at 29%. During a recent TV interview, Senator John McCain spoke about this distress expressed by voters, “10% of the American people, I understand, approve of the Congress.” He then added with some humor, “not even one individual in that 10% has attended one of my town hall meetings.”

One thing about which there is little doubt these days is that government spending cuts are on the way. The question of the hour is: WHAT programs will be cut and HOW MUCH money will be cut? The Medicare budget will be sure to be on the chopping block despite the fact that it is a sacred entitlement program.

Psychologists simply can’t afford to sit this one out. In the chilling film, “Silence of the Lambs,” Hannibal Lecter advised guests, “If you’re not at the table, you’re on the menu.” This quote captures the plight of psychology if we choose to do nothing and sit on our hands instead of engaging in political action. We must be at the table.

Despite the hard cold reality of the foregoing, all news for psychology is not grim. Take the composition of the Super Committee of 12, for starters.

Three of the twelve Super Committee members have been longtime friends to psychology over the years and relationships with each of them have been nurtured through AAP’s support. Patty Murray, the Committee’s Cochair; Max Baucus, Senate Finance Committee Chair; and Xavier Becerra, senior House Ways and Means Committee member have all been honored by AAP in recent years. AAP has worked diligently to insure that access to and open channels of communication with these individuals and many other important members of Congress remain productive. We must persist in these efforts, and with your support we can do so.

Elsewhere in this edition of Advance is a story containing a detailed history of AAP. I recommend that you read it and familiarize yourself with the course that psychology’s only political action organization has taken over the past 38 years. It is instructive to look at the obstacles that have been encountered by our political program during the past 4 decades. Not surprisingly, some of the most difficult challenges the program has encountered have emanated from within our own ranks.

Throughout its history, AAP has been an organization fundamentally supported and funded by the practice community. Today, in excess of 90% of AAP members identify “practice” as their primary concern, and in excess of 90% of AAP/PLAN contributors, identify themselves as practitioners. AAP has reached out to other segments of the larger psychology community over the year, and in recent years met with a modicum of success. Psychology’s education and training community. for example, has been making slow but steady progress in recognizing the importance of political action. AAP has hosted almost a dozen fundraising dinners for this community over the past decade. But the fact remains, plainly and simply, practitioners comprise the vast majority of supporters of AAP and AAP/PLAN. Because of this basic fact, AAP’s political agenda has been and continues at present to be directed toward advancing those legislative issues impacting practitioners.

While the APA and even the APA Practice Organization must represent a broader array of the larger psychology community’s interests in their lobbying agendas and direct their financial resources to address the concerns of this broader psychology community, AAP has the luxury of focusing the preponderance of its energies on a narrower segment of the psychology community, practitioners. AAP enjoys the kind of status of a specialty organization which in this case is defined by the percentage of members/ contributors who identify themselves as practitioners.

Thank you for your past support. I hope AAP can count on you to continue that support in 2012. Please consider increasing your support during this critical time for our profession. Help AAP to continue working to advance psychology’s concerns in federal government programs and among lawmakers in Washington. Send in your AAP membership dues renewals and make as generous a contribution to AAP/PLAN as you can. If you are so inclined, you could perform an additional really great service at no cost to your pocketbook. Corral a colleague and persuade her or him to join you by becoming a member of AAP. They can do so at the AAP website: www.aapnet.org.

Fall 2011 Newsletter

It’s impossible to ignore the plumes of smoke generated by all the politicians who are “crashing and burning” in Washington of late, each flame-out ignited by varying degrees of individual immoral behavior. The latest in a long line to fall was conservative Senator John Ensign (R-NV). No doubt, AAPers more than most psychologists, have given at least some consideration to what is causing these paragons of moral virtue to end up being hoisted by their own petards.

It’s easy for us to offer flip responses about this phenomenon: it’s the result of their arrogance or narcissism, or it’s the blinding effect of power, or the stress of political life, or plain unadulterated hypocrisy, or their use of projection, or a whole host of other things. As social scientists, though, we ought to be able to do better in providing a more substantive rationale for this behavior.

As it turns out, psychology has an entire literature which offers some insight into this troublesome growing trend. The research is not without weaknesses from my perspective, but it is most stimulating in helping to understand how public figures with careers built around denouncing moral turpitude—crusading prosecutors like Eliot Spitzer, evangelical leaders like Ted Haggard and Jim Bakker, socially conservative politicians like Mark Foley, David Vitter, Larry Craig, John Ensign, and Governor Mark Sanford—end up confessing to those very acts that they so vehemently railed against from their soapboxes. Though it’s a bit simplistic, my favorite current social psychology theory argues that developing a persona of morality increases the probability of going off the deep end of the depravity scale.

The study of how we form opinions of our own moral worth is a burgeoning field, and suggests that our thoughts about our own morality may, in fact, work in subtle ways to make hypocrites out of all of us—especially those who hold themselves in the highest moral esteem. People who complain bitterly against immorality in others are often themselves fixated on it, and more likely to succumb to its allure, according to the

With apologies to Lawrence Kohlberg and his stages of moral development, on which we were all professionally raised, my personal sense of these issues aligns best with the school of thought that suggests the existence of a fundamental principle known as “moral credentialing”. In a nutshell, the theory focuses on the existence of a kind of moral “set point”: an innate human type of thermostat that controls the amount of moral behavior in which we engage. The effect of this mechanism is that when we stray too far from the mean in either direction – even if it’s toward a “goody two shoes” status – we then reset to reestablish our set point, sometimes dramatically. Personal morality, it would seem, grows out of guilt, or an ex-post-facto story we tell ourselves about actions already decided on. As this explanation goes, it’s not a moral compass that guides our actions, but rather what we have is closer to a thermostat, stubbornly set to a comfortable moderate level, neither too virtuous, nor too depraved.

If someone has behaved morally or in some other way established a moral image, that frees the person to subsequently engage in less ethical behavior–sort of the moral equivalent of permitting yourself to suck down a strawberry milkshake after jogging for half an hour. For example, one study conducted at Northwestern University by Medin and associates found that participants asked to write a story referencing their positive traits donated just one-fifth as much as those who had to write a story about their negative traits.

Another experiment in the same paper concluded that this effect occurred because of the impact of the story-writing on participants’ self-concept–people who felt badly about themselves (having made negative traits prominent) bolstered their self-image by being more generous, while those who already felt positively about themselves were free to be less generous. Other research demonstrated that when study participants’ past behavior established their credentials as non-prejudiced individuals, they were more willing to express attitudes that showed prejudice.

Benoit Monin, an expert on moral psychology at Stanford, believes that many of our moral choices are guided less by abstract principles than by whether we presently feel like a good or bad person, and whether we see other people as good or bad.

Monin’s research reveals the interplay between self-image and morality. His key idea: Your sense of self-worth greatly affects your behavior and how you judge the behavior of others. If your self-worth is threatened, you’ll likely defend it and try to compensate. So you’ll rationalize your behavior by judging yourself more moral, or you’ll put down the morality of others. On the other hand, if you are confident that you are a good person, you can actually feel less compelled to act ethically.

Monin has identified psychological concepts and everyday situations where moral dynamics come into play. He coined the term “sucker to saint,” which means basically that people tend to cast themselves as morally superior when another person’s behavior makes them feel naive or foolish. For instance, if a colleague succeeds better than you by cutting corners when you have dutifully followed every rule, you would be motivated to derogate the co-worker as unethical, and elevate yourself as a paragon of morality to justify your inferior performance.

Similarly, people often resent “moral rebels,” or peers who do the right thing by refusing to go along with a questionable status quo. Their moral high ground implicitly puts you on lower moral ground. Their principled stand points out your failure to do the right thing. You might get annoyed and dismiss the “rebel’s” actions. This is especially problematic when people in organizations take a stand against a practice or raise difficult questions that require rigorous examination of data in order to arrive at a viable resolution, and must face resentment from peers who feel threatened by their stance.

In one study by Monin and his coauthors, undergraduates were asked to pick the most likely suspect in a burglary. They were shown three photographs and given information implicating the sole African American over the other two suspects, both white. Participants were later asked to rate fictitious participants who supposedly had been given the same task. The fictitious people were either “obedient” ones who picked the black suspect or they were “rebels” who refused to circle a face, saying the task was “obviously biased.” Other neutral participants first rated the fictitious participants and then did the task themselves—so they weren’t first implicated in the task. Participants who had been implicated by choosing the black face first reported disliking the moral rebels. Those who hadn’t yet made a selection liked the rebels and called them more moral. The conclusion is that once one has committed to a response that is status quo, the rebel makes you feel like a fool, and one tends to resent the person that you would have otherwise embraced.

At the end of the day, all of the research suggests we get more moral behavior from people who have to demonstrate their positive qualities to others. If so, it has important ramifications in many areas of what we do. Think about all the organizations in which we are involved both professionally and personally. Perhaps, we should be most wary of those who have the most leeway to behave unethically because of their positive image and frequent statements asserting moral positions–as it is precisely these people who will feel they have the moral license to do immoral things. I referenced a list of public figures that fit this mold above. Throw in Newt Gingrich, John Edwards, and Bernie Madoff for good measure. How can figures with such dedication, public esteem and records of so many good deeds engage in unethical behavior? The answer, according to “moral credentialing” theory, is simply that it is precisely their moral image that frees them from worrying about and therefore adhering to moral standards.

Of particular interest, providing people with lots of ethics training may actually backfire–as going through the training may make them overconfident about their own decision making, as well as feel that having learned ethics, they now have the right to, at least occasionally, violate what they have learned.

Another conclusion that has been drawn in this area is that people who, having done something wrong, then get a second or third chance, have a greater chance, if they decide to reform, of being scrupulously honest in the future. That’s because they have the most to demonstrate, both to themselves and others, about how moral they now are. Needless to say, this does not apply to sociopaths and other character disorders.

Strangely enough, to encourage the best behavior in your group, it might be prudent to not bestow excessive praise or positive regard upon members of a group, so they feel as if they must continually demonstrate their moral credentials. If moral credentialing is accurate, it is when people feel they have nothing left to prove that they don’t.

Summer 2011 Newsletter

There is a Chinese curse (the Chinese origins of which are in dispute) which says, “May you live in interesting times.” The first decade of the 21st century has proven to be an “interesting” time, to say the least. The results of the November 2nd election give added testimony to this fact. Maybe an undisputed Chinese proverb, “It’s better to be a dog in a peaceful time than be a man in a chaotic period,” would be more appropriate for our current predicament.

I am sure that most of you have had your fill of pundits offering opinions about why the elections went the way that they did, and what this means about the mood of the American people. You will not find musings about any of that in this piece. Instead, I will focus on what the election might mean for our community in terms of health care reform.

With the advent of the largest Republican electoral gain in the U.S. House since 1938, the campaign promises made by newly elected members of Congress clearly have gained increased importance.What will actually transpire on Capitol Hill during the 112th Congress is anyone’s guess, but there are a number of predictions that can be made with some degree of certainty

Repeal of the Patient Protection and Affordable Care Act—Easier Said Than Done One of the most talked about issues during and after the election is the vow by conservatives to repeal the Patient Protection and Affordable Care Act (PPACA). It is far easier to make a vow than to fulfill one. In this case, there are many compelling reasons militating against PPACA’s repeal.

First, it is of value to recognize that the last time lawmakers repealed a major piece of health care legislation was more than 20 years ago, when vehement opposition to a 1988 measure providing new Medicare prescription drug coverage in exchange for higher income taxes led to repeal 16 months later.

Second, even most conservatives realize that they won’t be able to repeal PPACA. The Senate will block all attempts to kill the bill, and in the worst-case scenario (if moderate Democrats cave), President Obama will veto legislation that attempts to overturn the legislation, or that even attempts to remove a major plank from the PPACA.

Still, many contend that Congressional opponents can act alternatively by refusing to approve appropriations needed to implement reform. However, convincing data suggests that this tactic will have its limits. It appears that only about $115 million of the approximately $1 trillion law is subject to the congressional appropriations process. It turns out that much of the funding for the health care reform law is mandatory spending, so to defund it the law itself would have to be successfully changed. If the law requires changing to defund it, we arrive back at the impasse wherein conservatives don’t have enough votes in the Senate, and certainly could not override the President’s veto even if they did. Given all these legislative obstacles, I think it is safe to say repeal is most unlikely. Republicans may well have their hands very full trying to manage the challenge of moderating their own tea party legislators’ expectations.

This not to say that there won’t be some minor tweaks to the law. However, change won’t be easy as critics learned in vivo in late November when they thought they would get their first win in the campaign to repeal PPACA. Instead they got a lesson in just how politically challenging a wholesale repeal might be when what should have been a slam dunk, turned into an impasse. One of the top priorities of both parties in the lame duck is the repeal of crippling expensereporting requirements in PPACA—requirements that would force businesses to file 1099 tax forms on all purchases over $600 in order to help raise revenue to fund the massive healthcare bill. Republicans and Democrats disagree on whether and how the roughly $19 billion in revenue that would be “lost” through repeal should be replaced. The differences were enough that two different repeal proposals (one each from both parties) went down to defeat in the Senate on November 29.

In reality, the fate of PPACA will probably be determined not in Washington but in state capitals across the country, where the GOP scored dramatic victories on November 2.

Republican governors and legislatures, who are charged with carrying out crucial parts of the law, will be able to pressure the White House to scale back some plans, including the extension of governmentsubsidized health benefits to millions of uninsured Americans.

State Republicans could also temper insurance regulations and compel a relaxation of new mandates set to take effect over the next few years. Republicans gained 11 governor’s offices, while losing three. The GOP will also control state legislatures in at least 25 states next year, up from 14. PPACA tasks the states with creating statebased insurance exchanges in which people who don’t get benefits at work would be able to shop for health plans starting in 2014. Resistance to the new law has already emerged in several statehouses. Legislatures in Minnesota and Rhode Island in the last year have rejected bills to create insurance exchanges. In California, legislation creating an exchange passed without a single Republican vote in the Senate. The kicker is that PPACA authorizes federal officials to operate an insurance exchange in any state that chooses not to do so. I think it is safe to assume that having the federal government march in to any state would be anathema to most state leaders.

Even in states with great opposition it is unlikely that the most critical Republican politicians will simply refuse to implement the law. GOP officials in many states that are fighting the law in court—including Virginia, Florida, Louisiana, Minnesota and Nevada—have already convened health care task forces to work on the overhaul. Stay tuned to these state matters where there is at least a possibility that turbulent opposition may gain some traction in erecting obstacles to PPACA.

Third, polls indicate that there is not an overwhelming dissatisfaction among voters about PPACA. Supporters and opponents seem to be nearly evenly divided with Ds more favorable and Rs less favorable toward the law. Looking back on the election, it is essential to realize that conservative gains in both Houses of Congress did not represent a vote against health care reform. An exit poll conducted by Edison Research indicated that nearly twothirds of voters identified the economy as the most important issue weighing on their minds; less than 20% named health care as their primary concern. Would a focus on PPACA repeal by the 112th Congress even remotely represent good judgement or a logical choice for the newly elected House Republican Leadership?

Fourth, although a great deal of fear mongering about PPACA, Medicare, etc., was used during the months before the election, almost all the issues used to engender fear have little basis in fact. Take the case of Medicare which campaign ads proclaimed was going to bankrupt the country. To the contrary, Medicare’s trustees have told us that the PPACA puts Medicare on the road to financial health, giving it an extra twelve years before the hospital fund even begins to fall short. As a result, Medicare has ample time to turn successful pilot projects into Medicare policy nationwide, changing how we pay for care, and how care is delivered. The history of these pilot projects has been promising in reducing costs while increasing quality of care. In the past, however, implementation has been blocked by lobbyists for the special interests whose oxen would have been gored if a number of these projects had been brought online. PPACA changes the rules of engagement by giving the HHS Secretary the power to roll out a project nationwide, without needing Congressional approval.

A related scare tactic used during the run up to the election falls under the umbrella of PPACA being unaffordable. It remains to be seen what the tab will be for the government (aka the taxpayer) when all invoices are turned in for this huge piece of legislation. This is indeed the central concern about PPACA: can the country afford it? However, for individuals or families, the amount that any family pays out of pocket will be capped; insurers will not be able to hike premiums without justifying their increases to government regulators, and generous subsidies will make insurance affordable for the middleclass.

If private insurers are not able to offer care that meets the law’s standards at a price that individuals and employers can afford, insurance companies have to come to terms with the fact that in 2013 or 2014, Congress is likely to reconsider the “dreaded” (by the insurance industry and all conservatives) public option. History suggests that over time, health care reform legislation, like other controversial social legislation (Social Security, for example, or the Civil Rights Act of 1964) is more likely to expand than to contract. Originally, Social Security did not include farm workers and domestic workers, which acted to exclude many AfricanAmericans.

Fifth, since reform already is underway, it won’t be easy to block it. Insurers are no longer denying coverage to children suffering from preexisting conditions. In just a few months, seniors who reach the “donut hole” will enjoy a 50 percent discount on prescription drugs; primary care doctors providing preventive care to Medicare patients will receive a 10% bonus, and both Medicare and new private sector insurance plans will no longer charge copays for preventive care. The Wall Street Journal reports that the number of small employers eligible for new tax credits (up to 35% of premium costs) are beginning to purchase insurance for their employees at a rate 30% higher than previously.

Impact of Reform on Mental Health
Part of my attempt to underscore why I think PPACA is not likely to go away is because I think the law will be a net improvement for psychologists and will improve upon the gains we derived from the The Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA). MHPAEA was a significant victory for the mental health community. As you recall, MHPAEA dictates that if MH benefits are offered in a plan, they must be at parity with medical/surgical benefits. This was a big advance; however, it stopped short of mandating that health plans provide mental health benefits in their coverage. A large number of group plans do offer MH or SA benefits and those plans must be at parity, but many plans still do not offer MH and SA benefits and the MHPAEA does not affect those plans. PPACA extends the MHPAEA to apply to any plan included in the health insurance exchanges, including all individual and group insurance policies. The MHPAEA only applied to group employer insurance plans for employers with more than 50 workers. It did not apply to Medicare, but did apply to Medicare managed care plans.

PPACA has taken this issue to the next level and requires that group health plans must offer mental health and substance abuse benefits in those plans offered within the American Health Benefits Exchanges which will be established effective January 1, 2014. It is estimated that 2530 million people will purchase coverage through the Exchanges. These Exchanges are marketplaces where people who do not have access to coverage through their employers can shop for health insurance at competitive rates. Initially, Exchanges will serve individuals and small businesses. Insurance companies are required to provide coverage, and that coverage must be equal to coverage provided for any other medical condition. Mental health benefits, along with maternity benefits and other provisions that once required payment of additional expenses, are now a mandatory part of basic care. For too long, mental health coverage was not considered essential. MH is now strictly defined in PPACA under section 1302 (b) as an “Essential Benefit.” This is a huge development and represents one of the most positive changes that will arise out of the passage of PPACA; more people will have access to affordable, effective treatments for their mental health needs.

PPACA also establishes National Depression Centers of Excellence that will be funded with 5 year grants. These institutions are intended to promote increased access to the best interdisciplinary, evidencebased care for people with depression, disseminate research and establish treatment guidelines.

Those of you who attended the AAP Century Club Reception in San Diego last August heard Senator Al Franken (DMN) speak. Among his many accomplishments during his first year in office was sponsoring a provision that was incorporated into PPACA which forces insurance companies to use their resources to actually provide health care to policy holders. Although not specific to mental health, it represents a milestone in the battle we, as professionals, have been waging against insurance companies for decades. Starting in 2011, insurance companies are required to spend 80 to 85 percent of premium dollars on health care and quality improvement. This regulation, known as the “medical loss ratio” provision, will make the insurance marketplace more transparent and make it easier for consumers to buy plans that provide better value for their money. As we all know, many insurance companies spend a substantial portion of consumers’ premium dollars on administrative costs and profits, including executive salaries, overhead, and marketing. Insurance companies that are not meeting the medical loss ratio standard of 80 to 85% of revenue on REAL health care, will be required to provide a rebate to their customers starting in 2012. In 2011, estimates indicate that up to 9 million Americans could be eligible for rebates starting in 2012 worth up to $1.4 billion.

During the second week of December, the Senate agreed unanimously and the House voted 4092 to postpone for another year a steep cut in what Medicare pays providers of health care. This action amounted to a $19 billion bipartisan deal. The measure also includes a oneyear extension of the 5% psychotherapy payment restoration. This will ensure the continuation of $30 million in Medicare reimbursements for 2011. The bill also provides financial resources to the Centers for Medicare and Medicaid Services (CMS) to process backlogged payments for claims since January 1, 2010 to which the restoration will be retroactively applied.

Known as The Medicare and Medicaid Extenders Act of 2010 (HR 4994), the Act averted for a year, a 25 percent cut in fees, and headed off what most experts agreed would be a disastrous blow to Medicare.

Most AAPers are well aware of this issue, know as the Sustainable Growth Rate (SGR). The APA Practice Organization has been lobbying vigorously for years to end the threatened fee cuts. In 2010 alone, five separate halts were legislatively enacted. Of note, no agreement on this matter could be reached in PPACA’s final form.

These SGR fee cuts were designed in 1997 to be phased in over many years as a way to control Medicare spending. Under pressure from providers including psychologists, and others, lawmakers have repeatedly put them off. When deferred, the cuts accumulate, forcing lawmakers to scramble for “patches,” a process that has wreaked havoc in providers’ offices nationwide.

We must still work to find a permanent solution in which seniors and health care providers can be confident. Democrats and Republicans have repeatedly promised a permanent fix to the unwieldy system that Medicare uses to pay providers. But such a solution could cost as much as $300 billion, a price tag that has become increasingly difficult to offset as lawmakers face pressure to control federal spending.

Government Spending on Health Care
The new 112th Congress most certainly will attempt to shrink discretionary spending. Government agencies have already submitted Federal Fiscal Year 2012 budget figures to the Office of Management and Budget. Earlier this year, the President issued guidance to all federal agencies requesting that each nonsecurity agency submit a budget request five percent below the discretionary total provided for that agency for FY 2012 than in the FY 2011 Budget. It is safe to assume that discretionary programs in the Department of Health and Human Services, Justice, and Education will likely remain level or shrink. So, in psychology, all of us who have interaction with agencies are likely to be in for some lean years ahead.

In light of revenue shortfalls in almost all of the States, the federal government provided a temporary increase in the Federal share of Medicaid spending that was scheduled to end on December 31, 2010 and was extended until June 30, 2011, although at a reduced rate. The combination of concern over federal spending, combined with changes in Congressional composition would suggest that chances of extending this federal support to states is unlikely to be extended again.
Good News/Bad News

Health care reform has been the engine driving many psychologists’ hopes for years. For many in the psychology family, the kind of change candidate Obama represented was a powerful elixir. For others, it represented a move in the wrong direction. Last March, to the amazement of many, Congress passed PPACA, the largest health bill in almost 50 years and I think it will be, on balance, an improvement for the provision of psychological health services.

If you think the 2010 election was depressing as many of you do, try not to fret too much about it. Scan a history of US elections and you will find one thing that you can count on: In a recession, Americans vote their pocketbooks. History also tells us that two years after the election of a new president, the midterm election tends to be a disaster for his party. Even Ronald Reagan took a beating; in 1982, House Democrats picked up 27 seats.

The storyline is familiar. The vanguard who originally supported the winning candidate feels betrayed that he has not delivered on their most euphoric expectations. In Obama’s case, some of his youngest and most enthusiastic supporters saw him as a SuperHero.

The bottom line is this: we are in the midst of the deepest recession since the Great Depression. True unemployment is higher than it has been at any time since the Great Depression.. That fact trumps every other issue.

Despite Congressional Gridlock, the two federal agencies which oversee a whole lot of health care, the Department of Health and Human Services, and the Centers for Medicare and Medicaid Services, will continue to conduct business and move forward. Over the next two years, reformers may well face a stalemate in Congress. Nevertheless, there is much that the CMS and the Secretary of HHS can do—without needing Congressional votes. As mentioned above, what most liberal critics of reform legislation don’t seem to realize is that PPACA gives the administration unprecedented new power to do what needs to be done, without having to go through Congress—and without running a gauntlet of lobbyists.

Ultimately, health reform should result in an expansion of public access to mental health services and cover many people who are currently uninsured, especially those with mental illness, who likely make up a significant portion of the uninsured population. This expanded coverage, coupled with other provisions in the law, should mean greatly increased opportunities for psychologists as practitioners, educators and researchers.

Let us all work hard to insure that these “interesting” times in which we live, also contain large portions of productivity and progress in promoting mental health for all Americans.

Winter 2011 Newsletter

The midterm elections are just around the corner and polling indicates that likely voters are not at all happy with the current state of the nation. With the economy still in the tank, the job number needle barely moving, and foreclosures expected to hit the 1 million mark this year, it’s no wonder voters are disgruntled.

Further evidence of the same has been seen in primary elections across the country. Senator Lisa Murkowski’s recent surprising loss in Alaska, raises to three the total of long term Senate incumbents [Specter (I-PA) and Bennett (R-UT)] who have gone down to defeat in the last several months. Nine term Congressman and former Delaware Governor, Mike Castle, went down to defeat in the DE Republican primary to another Tea Party extremist. Voter unrest is unmistakable.

It is also quite certain at this juncture that time has essentially run out for the Ds to get the economy back on track before November 2nd (never mind that this expectation begs the question of whether any party can be held responsible for this global economic meltdown, the likes of which has not been seen in 8 decades).

Without question, all these signs along with the historic fate of the party in power when a mid-term election is held do not augur well for election success for the Ds. In the 19 mid-term elections held since 1934, only twice has the President’s party gained seats in both the Senate and the House. Recent notable huge losses occurred in 1994 when the Ds lost 52 House seats during the Clinton Presidency, and in 2006 when the Rs lost 30 seats while Bush was in office.

Add to this picture two additional pieces of information and the prospects for a major electoral shakeup seem to be a slam dunk: 1) The typically staid Gallup organization’s latest data on voter enthusiasm which shows Republican voters are twice as likely—50 percent to 25 percent—to tell a pollster that they are “very” enthusiastic about voting this year, and 2) A “general reliability” factor of GOP voters being significantly more likely to show up for midterm elections. Young people and minorities are less likely to go to the polls for the midterms.

This composite of factors suggests the potential for what political scientists call a major “wave” election (rare occurrences when public dissatisfaction changes the political environment a la 1994) in which the Republicans stand to gain a large number of seats from the Democrats and in the process take back control of the House. Rs taking control of the Senate is now considered unlikely because of recent upset primary victories by far more conservative challengers in several states, giving the D candidates an edge.

On September 1st, Gallup reported Rs lead by 51% to 41% among registered voters in their weekly tracking of 2010 congressional voting preferences known as the generic ballot test. The 10-percentage-point lead was the GOP’s largest so far this year and is its largest in Gallup’s history of tracking the midterm generic ballot for Congress. But then on September 8 Gallup reported a dead heat at 46%-46% on the generic ballot question. This shift, coupled with the fact that Democrats led on the measure earlier in the summer, gives a very clear impression that voter sentiments are far from fixed on this matter. It goes without saying in elections as in life that it ain’t over til the soprano sings.

To keen observers (AAP members) of the national political scene, perhaps much of what I have stated above is old news. My goal was to set the stage for sharing additional data that I believe to be quite striking and is more helpful in shedding some light on the unusual current electoral landscape.

A survey by NBC News/Wall Street Journal asked people whether they believed that “government should do more to solve problems and help meet the needs of people” or that “government is doing too many things better left to business and individuals.” The principal pollsters are a Democrat and a Republican, so presumably no partisan slant exists. All of us are familiar with the D party mantra that more government is good, and the R party mantra that less government is desirable. The results show that in eight polls taken between 2002 and 2009, Americans preferred government to do more rather than less. In every single one, Americans favored greater governmental involvement, and in 2007 the margin was a whopping 17 points.

Starting one year ago, however, this trend changed. More respondents began to indicate that government was doing too much, by small but notable margins in four consecutive polls. What is noteworthy about this change is the fact that there was a clear shift among independent voters who are customarily neither as engaged, nor as ideological as either party’s faithful.

Historically, independent voters had sided with the Ds, by a few points in this poll, in favor of the government doing more. But that all changed a year ago. In the five polls since then, the opinions of independents shifted to a range of 10 – 21 points favoring the “less government” position.

A clear shift in swing voters’ attitudes about government’s proper role will most certainly have an impact on the Fall elections. Independents supported Ds for Congress by an 18-point margin in 2006, and by an 8-point margin in 2008. The shift among independents, if it holds, will translate into a significant number of seats for the Rs.

In the days following the Obama election in 2008, the two issues that now seem to dominate the dynamics of the upcoming election, a failing economy and a sense that the government was overreaching, were unimaginable. Not only are those factors now imaginable, They are palpable.

Congress returned today (September 14th) from their summer recess. One thing has been certain for the past two years in August when Congress was in recess, the country seemed particularly prone to heated hysterical-like reactions. Last year it was death panels and raucous town hall meetings, and this year it was the Ground Zero mosque, a Glenn Beck rally on the Mall, and many controversial demonstrations at 9/11 memorial observances. How bad the losses will be for the Ds in November will be more dependent on what transpires in the cooler months of September and October, and whether a cooler emotional response develops among those independent voters on November 2nd.

Whatever the final outcome is in November, we psychologists will have our full share of work to do to make new friends on Capitol Hill and insure that we maintain our old friends, as well. Sadly, we will say goodbye to our close friend Psychologist/Congressman Brian Baird (D-WA) who is retiring in January. We will also be losing Congressman Patrick Kennedy (D-RI) who has been a staunch advocate for mental health. AAP will continue to work diligently with the APAPO Government Relations team to forge working relationships with new and old members of both political parties who support the role of psychologists and mental health in federal public policy.

Fall 2010 Newsletter

It’s no secret that politics is an oft-maligned profession. One of Ronald Reagan’s favorite quips, “It’s been said that politics is the second oldest profession. I have learned that it bears a striking resemblance to the first,” reflects the essence of the matter. Yes, politics is about many things, but to be certain, it isn’t about perfection. Over the past twenty years, AAP/PLAN has supported hundreds of candidates who are not only sympathetic to psychology’s concerns, but many have been instrumental in pushing forward our legislative agenda. Regardless, I’d bet there isn’t a single one among those hundreds who would completely satisfy the average psychologist’s requirements for being a “perfect” politician. What’s more, if we held each politician up to the scrutiny of the larger group in psychology, I am certain consensus could never be reached about any candidate’s merit.

This is not meant to be an indictment of politicians. On the contrary, it is more a statement about the diversity of opinions existing among psychologists and the amount of growth that is needed among psychology’s rank and file in order to develop a fully functioning psychology advocacy program. We are anything but a homogeneous group when it comes to our political beliefs. In this regard, we are not unlike the general population of voters today where there is more divisiveness than ever about candidates and political parties. Psychologists have strong opinions about a wide range of matters, sometimes to the detriment of advancing the field. Take for example the recent polarization we see in psychology concerning prescribing privileges, or the recent interrogation of military detainees controversy.

Many believe that we psychologists tend to have a greater than average number of political liberals among our ranks. I don’t doubt this, but I have been surprised by the substantial number of conservatives there are among us. They are not a very vocal minority for obvious reasons. Moreover, the social leanings of all psychologists on issues ranging from abortion rights, to gun control, to immigration reform, to you name it, are all over the map. AAP/PLAN strictly avoids involvement with or support of any of these kinds of matters. AAP instead focuses ALL of its attention and resources on the one area in which there is universal agreement among the ranks, promoting psychology in the public policy arena. Psychologists, despite our strong traits of independence, are in the main, collectively united about the importance of advocating for the science and profession of psychology. We all assign a high priority to advancing the values that psychology can bring to the public whether it be in the health care, research, science, or academic arenas.

Unfortunately, there are still many psychologists who haven’t gotten the message that to advocate effectively we need roll up our sleeves and get involved in all aspects of the political process: lobbying, grassroots activity and political giving. This is not breaking news, of course. You’ve read this same screed repeatedly in the pages of Advance for the past 20 years. An early Greek “psychologist” some 2,500 years ago said it quite succinctly, “One of the penalties for refusing to participate in politics is that you end up being governed by your inferiors.” Say what you will about Plato, but he knew what he was talking about on this issue.

Most of our colleagues still don’t appreciate how critical it is for us to support legislators who will be allies for psychology at both the federal and state levels. While all the other issues mentioned above and more (abortion rights, gun control, immigration reform, etc.) may remain high top priorities on a personal level for each individual, psychologists must evolve to the next level and recognize the critical importance of separating their personal agendas from their professional ones. Our profession can’t afford the luxury of supporting only “perfect” candidates who meet all the various and sundry litmus tests that so many psychologists claim to utilize to determine who will receive their support.

Pragmatism appears to be a foreign concept to many among us. We need to heed the words of the great German statesman, Otto Von Bismarck, “politics is the art of the possible”. A case in point which is illustrative of what I am referring to occurred last winter. In March, Olympia Snowe (R-ME) was honored at an AAP Leadership Dinner. Her record of support on matters of great significance to psychology during her combined 32 year tenure in the US House and US Senate has been exemplary. Even so, AAP received a fair amount of criticism from some quarters in psychology for selecting Senator Snowe as an honoree, much of it from psychologists from her own state of Maine.

The central theme of this criticism revolved around the Senator’s unwillingness to cast her vote in support of the final health care reform bill (HCR) in late December. While she was the only Republican to vote the health care reform bill out of the Finance Committee in October, she did ultimately vote against the final bill on the floor of the Senate on Christmas Eve.

It must be pointed out that the Senator’s opposition to the final bill was not just some contrived matter resulting in a lockstep party vote. Senator Snowe had repeatedly stated her belief that the status quo in health care was unacceptable. Her dedication to crafting an HCR bill is what originally motivated her to join with a group consisting of six members of the Senate Finance Committee last summer in the only bipartisan effort in any committee of the House or Senate. The so-called Group of Six, convened by Finance Committee Chairman Max Baucus met 31 times, week after week for over four months, to debate policy and politics was absent. Snowe said she was troubled that when the Finance bill was melded with the measure reported by the Senate HELP committee it was without the more inclusive, collaborative process participated in up to that point and instead it was done in the shadows, without transparency, just to garner the necessary 60 votes and nothing more. She felt the final Senate bill had taken a dramatically different direction since the Finance Committee bill. The final bill was 1,200 pages longer and included a new employer mandate that Snowe felt could annihilate the job growth potential she thought was vital to the economic recovery.

These are just a few of the objections she raised before the final vote. Whether you agree with the issues she was concerned about or not, it would be a real stretch to say she had not been anything but an honest broker with regard to HCR. Her final position before the vote, was to urge her Senate colleagues not rush to vote and she suggested that instead of taking a 3 week recess for the holidays, the Senate should return to Washington to continue debate about HCR on January 4th.

It borders on being ludicrous to accuse Senator Snowe of: attempting to drag HCR down, or simply voting party line, or just trying to block any measures that the Democrats might propose, or being opposed to any HCR at all, as was the case for many who voted in opposition to the bill. But that is precisely what a surprising number of psychologists expressed during the months leading up to the AAP Snowe dinner. Following are only a couple of the many responses received from tens of psychologists who declined to contribute to the Snowe dinner:

“I am not sure what position she will take on important questions related to psychology such as medicare reimbursements, but given her position on the current effort to reform health insurance I don’t see how I can contribute to fund raising efforts on her behalf.”

“I have to say I am so extremely upset by Olympia Snowe’s obstruction of the passage of a national health care reform plan that I am going to be working *against* her re-election. I think she’s been bought out by the insurance companies and big pharma.”

A reasoned response to these and similar statements to those above is as follows: “It is understandable that for many it was disappointing that the Senator didn’t support the HCR bill in the end. But it is vital that we as a profession mature to the point that we recognize that elected officials will not be in synch with every issue we believe all of the time.

Olympia Snowe has made many contributions to improve the mental health of all Americans during her career in Congress and she has been a staunch supporter of psychology’s legislative agenda. Most recently, for instance, Snowe introduced the Mental Health Co-payment Equity Act which reduced the co-insurance requirement amount for Medicare psychology visits from 50 percent to the 20 percent level required for all other Medicare visits and eliminated discriminatory co-payment rates for outpatient psychological services in Medicare. In addition, Snowe co-sponsored The Lane Evans Healthcare Benefits Improvement Act which would ensure that veterans suffering from mental health disorders will receive necessary support and treatment. She was an early and vocal supporter of the historic Paul Wellstone Mental Health Equitable Treatment Act. She has been very supportive of the restoration of psychologists’ reimbursement rates under Medicare. Although she did not concur with the HCR bill that was finally passed in the Senate, her attempt to work out a compromise was undertaken in good faith and her proposal was genuine and of considerable merit. She will continue to play a pivotal role in health care especially because the composition of the Senate is likely to contain fewer Democrats after next Fall’s election. That will make reasonable Republicans like Senator Snowe even more influential than she is currently. The impact of spending 2-3 hours of time at a dinner immersed in psychology’s issues will no doubt influence Olympia Snowe to be an even stronger advocate for psychology and mental health concerns than she was previously.

Don’t assume that disagreeing with a legislators position on a single issue is the only reason (“excuse”) psychologists raise to justify their non-participation/contribution to events like the Snowe dinner. Our colleagues are quite creative, of course. One who declined to make a contribution to the Snowe dinner responded as follows:

“I’d be pleased to support financially any candidate that supported legislation that allowed appropriately and ethically trained psychologists to prescribe psychotropic medications, as per APA policy. Given that Senator Snowe, to my knowledge, has not even been approached by the APA on this issue, I am going to decline your request to support her, or any other candidate any APA governance body puts forward, without first knowing their stand on this important issue to us all.”

Never mind that this issue is not one over which the U.S. Congress has any jurisdiction, other than the VA and Indian Health Service.

Prescribing privileges are a scope of practice issue that falls under the jurisdiction of individual state laws. Thus, state legislatures and governors control psychology’s future on prescriptive privileges for psychologists. The APA Practice Organization has provided substantive support for the efforts of many states with a great deal of money and legal resource availability. At the federal level, AAP and APAPO supported the federal military psychologists’ training program. This is the model that states use to refute psychiatry’s baseless claim that psychologists who prescribe will do great harm to patients.

Following are only a few more of the many additional reasons psychologists routinely give for the their non-involvement in the political process. Each is followed by a brief rebuttal:

Can’t afford it—if every psychologist contributed just $10/ month, psychology would have the largest PAC in the health care industry, by far.

Supporting this candidate doesn’t benefit me—when psychology succeeds all those in the psychology family benefit.

I already pay dues to APA to advocate – APA is legally prohibited from any involvement in the political process, although some lobbying activities are permissible, political action is forbidden for a variety of legal and tax reasons.

I don’t believe in buying votes – no votes can be bought, but access to educate elected officials is facilitated through campaign support.

Our research data provide sufficient evidence to support the need for the legislation we are requesting – Decisions in Washington are almost always based at least as much or more on political considerations as they are on research/facts.

For too long, psychologists have avoided full participation in political action. The entirety of psychology’s political action program is still riding on the shoulders of far too few of us (less than 10%). I know that if you are reading this column that I am writing to the choir. But we need your help on this. Please have a personal conversation with a colleague. Make it a point to reach out to as many colleagues as you can and urge at least one colleague to join with you in supporting psychology’s advocacy efforts. Sit down with them and show them how easy it is to participate at: www.aapnet.org. While it is true that we aren’t causing change to happen as fast as we’d all like, we are doing what’s possible, in true Von Bismarckian fashion.

Summer 2010 Newsletter

President Obama made history on March 23rd with the historic signing of the Patient Protection and Affordable Care Act (PPACA). This health care reform legislation took some 70 years to successfully come to fruition. That makes the long battle to enact mental health parity seem like it occurred at the speed of light by comparison. Eighteen months ago, psychologists celebrated another historic signing. At that time the Paul Wellstone and Pete Domenici Mental Health Parity & Addiction Equity Act of 2008 was signed into law. Our joy then concentrated upon the thrill of success after slogging through more than a decade of hard work directed at finally ending decades of discrimination against those with mental disorders in private health insurance plans. Although the law was not a total panacea (managed care still has too much control of treatment), it represented a giant step forward in putting mental health benefits on a par with physical health benefits.

What we didn’t know eighteen months ago, however, was that the parity law would be the proverbial gift that keeps on giving. In fact, without the parity law in place when the debates about the recent health care reform bill were occurring, we might well be singing the blues today. The parity law not only established equality in health insurance between mental and physical health, but, perhaps of greater importance in a variety of ways, was the absolutely indispensable role parity played during the year after it was enacted. By virtue of the fact that the parity law was solidly in place, the PPACA’s handling of mental health and psychology benefits was most equitable. Mental health was handled as assumed components in all discussions about the bills rather than what might have been a more dismissive manner requiring a fight for every inch of inclusion, as had historically been the case prior to parity’s passage.

APA Practice Organization lobbyists participated actively in discussions around health care reform, with the goal of ensuring integration of psychological care in all health plans, not the most basic kind of inclusion as has always been the case in previous reform attempts. A key aspect of the just passed legislation was the extension of the mental health parity protections established into law in 2008. Not only are these protections extended to all plans in what are called the Exchanges, but mental health and substance use benefits are a part of the essential benefits package created by this legislation. For the 67 percent of adults and 80 percent of children who need mental health care that do not receive it, this victory cannot be understated. Additionally, the PPACA marks a leap forward towards the transition from an illness focus for the health care system to one which is preventive, collaborative, and patient-centered.

It is very important to understand that the prominence of mental health treatment and benefits in the new law is largely the consequence of all the debates, the lobbying, the battles, and the struggles to gain support from members of Congress that occurred during the ten years of construction of the mental health parity law. During those years, members of Congress of all stripes became sensitized not only to the significant incidence of mental disorders among Americans, but also to the value derived from providing treatment to those with mental health problems. During the parity debates, a substantial number of members of Congress developed a new set of beliefs about mental health. The stigma about mental disorders was diminished as more science based information was widely circulated across a broad spectrum of political ideologies. As more members of Congress understood the multi-faceted issues involved with mental health, parity legislation became the law of the land. Clearly, the mind-body connection if you will, and the attention it received by lawmakers would prove to be invaluable in all discussions about the inclusion of psychology/mental health in the bigger picture (overall healthcare reform) which followed almost immediately on heels of parity’s passage.

Imagine the obstacles we would surely have encountered in the halls of Congress and at the White House if parity legislation had not been enacted a short 18 months ago. Instead of fighting for the most fundamental sort of inclusion of psychology services in the bills that were written in both houses of Congress, we were able to start our discussions by focusing our energies on the integration of psychology with physical health services in order to remain consistent with the already enacted mental health parity law. There was no need to sell lawmakers on either the need for our services or the value of them. The recent ten year parity debate had filled in any holes that might have existed in these two areas much to our great benefit.

From the restoration of psychology reimbursement rates in Medicare, to increased recognition about the mental health problems in returning veterans, to acknowledging the importance of prevention matters in mental health, to the mental health parity law, psychology has made great strides in the past decade. I was privileged to attend the White House Conference on Mental Health in 2009 which was Chaired by Al and Tipper Gore. One of the main issues addressed at that time was the “stigma” of mental health treatment. It is very reassuring to recognize how far we have come on this matter on Capitol Hill. The progress can be measured in the PPCAC.

Overall the PPACA will benefit individuals with mental health disorders. First, it will expand access to health insurance coverage (through both private plans and Medicaid) and make it more affordable and quality-driven. A big improvement will involve setting standards for health insurance policies so as to protect consumers. In addition, the law will set minimum requirements regarding services that health plans must cover, including mental health and substance abuse services in that mandate.

Of note, for all of us, is a feature of the law that will encourage more coordinated primary care and specialty mental health care, promote preventive services, foster workforce development initiatives, and make other changes designed to improve the quality and availability of services that people receive.

As is always the case in the public policy realm, the enacting of legislation requires great patience. However, sometimes the impact of legislation can reach far greater than was originally envisioned. So it is in the case of the Parity Act. It has already proven to be essential in ways that extend beyond its original intent.

Spring 2010 Newsletter