AAP Newsletters

For most of us, attempting to follow the complexities of any legislation in the making is an exercise in frustration and confusion. The health care reform bills under current consideration are no exception. In fact, watching a bill become a law is often joked about as one of two processes you should never watch, the other is making sausage. Yet, these days you can’t pick up a newspaper or watch the evening news without being bombarded by evidence of lawmaking ad infinitum as pertains to health care reform.

If the march to a bill’s final passage seems long, laborious, and never ending, that’s because the actual process IS truly never ending. Yes, bills do become laws, but the process doesn’t end with the President’s signature in the Rose Garden. The actual signing of a bill into law is, metaphorically speaking, akin to a practitioner being granted the doctoral degree. While that is a great accomplishment, there still are many additional hurdles to jump over before one can hang out a professional shingle (internship, licensure, etc.). Even after licensure the process doesn’t end, practitioners must continually update their training through annual CE requirements in order to maintain their right to practice independently.

A good illustration of the long slog of lawmaking is the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) that will provide mental health services and substance abuse coverage to 113 million Americans.

We all rejoiced when this historic measure was finally enacted a year ago (after more than a ten year battle until passage). But our work is not done on this measure. The current phase in the process is every bit as critical as the initial ten years because it is here that the rubber meets the road, so to speak. It is at this juncture that the new law is scrutinized down to the last detail and the working federal rules and regulations are stipulated.

Vigilance is the keyword during this stage in order to insure that the intent of the legislation does not get lost in the interpretations of the rule writers. The Federal rules and regulations are the actual enforceable laws authorized by the legislation enacted by Congress.

While the MHPAEA was clearly landmark legislation requiring years of laborious planning, debate, compromise and reconciliation in Congress, the work of creating the federal rules and regulations, some would call these the real laws behind Acts, happens largely unnoticed in the offices of the government agencies rather than the halls of Congress.

With regard to the MHPAEA, the following Federal Agencies: Health and Human Services, Department of Treasury and the Department of Labor are the regulatory agencies empowered to create and enforce rules—regulations—that carry the full force of a law. After passage of the MHPAEA, the three above agencies were instructed to issue regulations before January 1, 2010, the effective date for the Act. HHS Secretary Kathleen Sibelius has already postponed the date of issuing regulations to sometime in January. It is essential that the regulations are issued for many reasons. However, the fundamental reason for issuance of rules is to avoid misinterpretation of the law when it is implemented and, in the case of the MHPAEA, to ensure access to critical mental health and addiction services as prescribed in the law.

The essential role of the rules and regs is to enforce the law. The Department of Labor insures compliance for ERISAregulated health plans, Health and Human Services oversees compliance for all other health plans, and Treasury exacts tax penalties for noncompliance. All three departments will jointly enforce the law.

This process of creating and enacting federal regulations is generally referred to as the “rulemaking” process. Rulemaking requires the highest level of nitty gritty detail, a virtual treasure trove for Bruno Klopfer’s “dd” types. In the case of the MHPAEA, for instance, the APAPO had an opportunity to respond to six questions developed by the federal rulemaking agencies. The APAPO responded to these questions with a twenty-three page letter sent to the agencies last May. Included in that letter was a comprehensive response to the six questions the agencies raised in a formal Request for Information, as well as a response to questions raised by the employer and insurer community regarding whether a group plan may have separate but equal financial requirements for mental/substance use benefits was offered.

In this phase of the process, psychology is specifically concerned that the agencies take special care to address issues such as scope of services, medical management, treatment limitations, and the use of “separate but equal” deductibles.

Of note, a recently published study examining California’s experience with its own state parity law (on the books since 2000) could be valuable to the success of the MHPAEA. The study, by researchers at Mathematica Policy Research and the Substance Abuse and Mental Health Services Administration (SAMHSA), used data from interviews and focus groups to draw conclusions about the success and failures of the California law from 2000 to 2005. Among the findings: • Costs associated with parity were in line with, or even below, the projections.
• Most health plans responded to the parity law by lifting limits on the annual number of days allowed for inpatient treatments and the number of visits allowed for outpatient treatment. • Concerns arose over the use of “medical necessity” clauses to authorize treatments and control costs. Medical necessity is typically defined as the need to supply a service for a condition that could endanger life or cause significant illness, suffering or disability and for which there is no adequate, less costly alternative available. • Consumers also complained about being referred to lists of mental-health providers only to find out that providers on the list were not taking new patients. • Health insurance providers felt the list of diagnoses covered under the parity law was arbitrary in excluding certain diagnoses. • Some doctors reported that they chose a parity diagnosis for a patient in order to ensure insurance coverage although it wasn’t the most accurate diagnosis. Some doctors said they had little flexibility to change a client’s diagnosis if he or she improved because they believed the health plan would then stop providing coverage for continuing care or care for a lesser diagnosis. • Nearly half of Californians polled in focus groups were unaware of the parity law.

Most, if not all, of these findings are well known to professional psychologists. Now, though, there is a public context, in which to actually examine these issues. We are hopeful that the rules and regs phase of the MHPAEA will create binding language that will insure the best outcomes for the new law as it was intended. We are well aware that the “medical necessity” criterion is one that is in dire need of very careful regulation, and recognize it is one of the thorniest issues in the entire area mental health benefits. Psychology’s public policy team will have their hands full in insuring that these matters continue to be kept front and center in the minds of lawmakers who have a vested interest in the MHPAEA. After all, we are most cognizant of the fact that the job continues long after a law is born. Keep your eye on the ball and continue your support for our efforts so that we are better able to make headway on these matters.

Finally, though it is not in the province of federal rules, but very important nevertheless, a strong suggestion made by the authors of the California parity study should be noted which encouraged the use of public education campaigns to accompany the introduction of the federal parity law, underscoring that the effort could yield another benefit. The authors correctly pointed out that enhanced public education may also lead to reduced stigma associated with mental illness. We have made progress in this area, but there is still further room for growth. Here’s to a productive 2010 for all of us.

Winter 2010 Newsletter

Congress will return this week from their “summer of discontent.” It was a recess punctuated by town hall democracies which were brought to new lows with death threats, fingers bitten off, and shockingly high levels of incivility on display. During the break, real Health Care Reform (HCR) has shifted from a promising probability to a slight possibility requiring life-support intervention at the moment (Labor Day Weekend).

Because HCR is the first major test of the energized “Yes We Can” folks in Washington, a lot is at stake, even beyond that which has always been at stake around this issue for the past 70 years. Opponents of reform, of which there are many, have pulled out all the stops because they well know that once a large scale, comprehensive health program is enacted, it will be virtually impossible to annul.

These opponents have successfully used conventional media outlets and the Internet to try to retain the control that power brokers have enjoyed for more than two centuries, by inciting scared conservative rightwingers who are afraid of losing their grip on the status quo.

This fear is manifested in political perspectives and extremist beliefs which are most astonishing to moderate thinking folks. Visit a few conservative web sites if you want further evidence. For example, a whopping ninety-one percent of 2,600 self-identified conservatives said Obama was either a “socialist,” “Marxist,” “communist,” or “fascist”at ConservativeHQ.com.

Small polls like America’s Watchtower show the Obama- Socialist connection at 68 percent, and a Newsmax.com web poll with about 32,000 respondents characterized Obama as a Socialist at an 84.95 percent rate.

The more sane and scientific AP Poll, which does not allow for stuffing of ballot boxes on the web shows that, as of the end of July, 2009, only 6 percent of the public would describe Obama as “liberal,” with fewer than that, less than 3 percent, labeling him as a Socialist. But, and this is a big “but,” they are an extremely vocal 3 percent.

Approximately 91 percent of weekday talk radio programming is conservative, and just nine percent is progressive. However, “43 percent of regular talk radio listeners identify as conservative, while 23 percent identify as liberal and 30 percent as moderate.“

Liberals have the far right media stars like Rush Limbaugh and Glen Beck to contend with. Conservatives rail about Keith Olbermann. And, psychologists even have their own, Dr. Laura, cross to bear.

In the past month, we have witnessed yet another illustration of political ideologies overriding reality. In this case, however, many consider the reality to be crucial modifications desperately needed in the nation’s health care system.

Instead of informed discussions about changing the system, we were fed a constant diet of conservative pablum by opponents of HCR. These ideological attacks have been the trusty standard weapon with which conservatives have battered and often derailed solid public policy reform proposals for more than a decade. Conservative beliefs about the power of free markets to correct all the ills of the health care system, along with the mantra of limiting the role of government have once again dominated the discussion of HCR. And at the end of the day, while HCR prospects weaken, HCR opponents have added absolutely nothing in the way of providing alternative solutions.

Sadly, that strategy has worked for them, time and again: assault issues ideologically, offer no plan to correct the problem. Our fellow Americans who are screaming out with fury at town halls aren’t offering ideas, they’re responding to the taunts of the right-wing small government provocateurs. They have successfully been agitated into speaking out against their own self-interests. Of course, this is nothing new. For years, we have seen low income right wingers consistently vote against their pocketbooks to support emotionladen socially conservative issues.

Could it be that simply the image alone of “big government” really has the power to interfere with Americans’ ability to think rationally, or to make use of average intellectual capacity? Haven’t we moved beyond the kind of Orwellian fears that were prevalent in the 50s and 60s. The answer, of course, is that a small but powerful cohort of Americans remain highly concerned about a dystopian governmental takeover despite the fact that it has been 25 years since 1984 came and went without so much as a hiccup.

I get a real kick out of the way conservatives vilify all programs or agencies in which government is involved. Could we abide a health care system, let’s say, with the efficiency/ quality of the US Postal Service? I happen to think the USPS is a real phenomenon even though it has imperfections For 44 cents, we can send a letter to someone 3,000 miles away and it will be delivered in a matter of days. Sure, FedEx will get it there in less than 24 hours, but at a cost that is 25 times higher than the USPS. I know it’s not the ideal system, but it works pretty darn well.

If you really want to measure inefficiency, recall the last time you went to the mat with your private health insurance company about a claim that had not been paid, or had been inaccurately processed by the company, or had paid an amount far less than they were required to pay. The condition typically arising from these interactions gives new meaning to the term “experimental neurosis.”

But let me return to the discussion of how effectively conservatives have waged political battles with an almost total absence of real ideas, relying only on ideologies for ammunition. What does this say about Americans? Why do so many of our fellow citizens succumb to these arguments that are so fundamentally flawed? I think this question is integrally related to similar actions we have frequently seen in elections.

Psychologist, Drew Westen, an unabashed liberal, focuses his research on the interaction of psychology and politics. He takes the unlikely position that liberals and the Democratic Party should, for the most part, forget about issues, policies, even facts, and instead focus on feelings when articulating their public policy agenda. As discussed in this column last summer, Westen’s book, “The Political Brain”, takes a different tack than another recent popular political tome, “What’s the Matter With Kansas?” by Thomas Frank or Al Gore’s “Assault on Reason,” which try to explain voter behavior in terms of self-interest and factual analysis.

Westen’s message is the exact opposite. Franks and Gore explain why we should be more rational instead of why we should bring more passion into politics. What he calls “the dispassionate view of the mind” which has guided Democratic thinking for 40 years is deeply misguided according to Westen. What decides elections, he maintains, are people’s emotional reactions, even if they don’t know it.

A cursory look at some data does seem to confirm that voters are driven more by emotions than by a rational, logical analysis of a candidate’s record and positions. Could there really be any other explanation for a measurable segment of the electorate responding so positively to Sarah Palin as a serious Vice-presidential candidate? Or take, for instance, the fact that so many anti-immigration Republicans pulled the lever for McCain despite his relatively soft position on illegal immigrants. Or the fact that in last year’s primary race, Hillary’s well constructed, highly engineered ten-point plans didn’t move voters as powerfully as Barack’s inspirational oratory.

And so it may be with the current battle around HCR. Although, I often question the intelligence level of the average American when we focus of public policy issues, it is far too simplistic to conclude that the problem herein lies with the fact that Americans are just plain dumb. H.L. Mencken, the great journalist and essayist often aimed his wit and criticism at the shortcomings of democracy and middle-class American culture. One of my favorite Mencken statements is, “no one in this world has ever lost money by underestimating the intelligence of the great masses of plain people. Nor has anyone ever lost public office thereby.”

American intelligence, and here I am more narrowly defining intelligence as “political” intelligence, has been explored. Ilya Somin, George Mason Law Professor, looked at the 2008 presidential election last year to try to determine the extent to which the results were likely to be influenced by, for want of a better term, political ignorance.

In general, it is fair to say that primary voters are likely to be better-informed than the average citizen, and Iowa caucus goers even more so (because attendance at a caucus requires a much higher investment of time and effort and therefore tends to draw more committed voters with a higher level of interest in politics). Nonetheless, a Des Moines Register poll of likely Iowa caucus voters suggested that ignorance may well have had a major impact even in the election with perhaps the country’s best-informed voters. The poll asked “likely” participants in the Republican and Democratic Iowa Caucuses whether they believed they needed more information about 19 major issues in the campaign, including health care, the Iraq War, social security, the economy, national security, etc..

It is striking that large numbers of likely voters admitted that they needed “more information” on a variety of major issues. For example, 56 percent of Republican voters and 50% of Democrats admitted that they needed more information about Social Security – despite the fact that this issue had been extensively debated for years. Similarly, 52% of Republicans and 46% of Democrats admitted they need more information on America’s “relationship with other countries” – even though foreign policy has been perhaps the most important issue on the political agenda since 9/11. Over 40% percent of Iowa voters in both parties admitted to lacking information on eight of the other issues surveyed, including health care.

These figures very likely understate the true degree of ignorance among likely Iowa voters for at least two reasons. First, as we all know, surveys show that many respondents are unwilling to admit ignorance. For example, 20-30% will express opinions on nonexistent laws made up by pollsters rather than admit that they haven’t heard of them. Second, the more ignorant you are, the more likely you are to be unaware of the full depth of that ignorance and to underestimate the amount of information you need to be a better voter.

It’s also worth noting that Iowa caucus voters are perhaps the best-informed in the entire country, given the amount of exposure they have to campaign information and the fact that caucus voters are likely to be better-informed than primary voters. If Iowa caucus voters – by their own admission – lack adequate information on numerous major issues, the rest of the electorate is likely to be even worse.

I have no doubt the data reflect an accurate picture of the dearth of knowledge the average voter brings to the voting booth. Candidates and elected officials often seem oblivious or in denial about this phenomenon, however. I marvel at the way in which elected officials respond to one of the most common media questions which is almost routinely asked during the course of a standard interview. The interview typically goes something like this, “Senator Jones, do you think your constituents will support the legislation you are sponsoring?” “You know, Mr. Cronkite, I have come to believe that the American people always know what is right, and they will be able to see through all the confusion thrown up by my opponents to find the truth inherent in my bill”. When I hear politicians respond in this way, I always think to myself, what American people is he or she talking about? The American people I see are regular listeners, if not devotees, of the shrink-impostor of the airwaves, Dr. Laura. If Dr. Laura told them there was gold in their veins, they’d chew off their ankles to get at it. I know that’s harsh, but think about it.

Political groups in this country are incredibly well entrenched in their dogma as never before. Questioning political intelligence is fair, but more plausibly we must recognize that we are a fear-driven culture. There is a large segment of the population that, no matter how well you document it, will not let a good fact get in the way of their fears about almost any issue, including health care reform. As psychologists, we can help the electorate understand and respond differently to their emotions which inevitably collide with reason. Invariably, emotion wins. Who better than psychologists to help the electorate navigate through these murky waters?

I sincerely hope that our elected officials will get their collective act together in the coming weeks. They must demonstrate courage, transcend the obstacles that are lacking in any semblance of substance, and begin to resolve the problems so damaging to our ability to provide high quality, costeffective health and mental health care to all who need it in this country.

Fall 2009 Newsletter

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.

Summer 2009 Newsletter

Note: The following column consists of the remarks I delivered at the Political Plenary session during the APA Practice Organization’s State Leadership Conference in March. Although all AAP members are far more sophisticated about the importance of political giving, the content below is offered to help assist you in disseminating the message to those of your colleagues who have not, as yet, gotten “on board.”

I know that some of you, perhaps many of you, may perceive that involvement in the political process is offensive or distasteful. Further, many may even think that politics has no impact on their lives. Please take a few minutes to read a short description of a typical day in the life of one psychologist who closely resembles the model stereotypic “cynical-about-political-involvement” psychologist. I’ll call him “Joe the Psychologist.”

Joe gets up at 6am and fills his coffeepot with water to prepare his morning coffee. The water is clean and good because some fervent political activist fought for minimum water quality standards. With his first swallow of water, he takes his daily medication. His medications are safe to take because some zealots in D.C. fought to insure both their safety and that they work as advertised. He prepares his morning breakfast, bacon and eggs. Joe’s bacon is safe to eat because wide-eyed believers fought for laws to regulate the meat packing industry.

Joe dresses, walks outside and takes a deep breath. The air he breathes is clean because some environmentalist fought for laws to stop industries from polluting our air.

Joe begins his workday. He has a good private practice despite the fact that his income has flattened in recent years. He is able to practice independently without need for supervision by a psychiatrist because some passionate trailblazing psychology leaders fought for these rights in the ’70s. He can bill his patients’ insurance companies for services he provides because a bunch of ardent politically active psychologists fought to establish a law permitting this a couple of decades ago. Beginning 18 years ago he became able to bill Medicare for treatment he provides to elderly patients because of the fervent battles psychology activists and their Washington-based APA lobbyists fought in, since psychologists were excluded from the Medicare Program for its first 25 years of existence.

Joe is home from work. He plans to visit his father, now retired, this evening at his farm home in the country. His father lives on Social Security and a union pension because some forward thinking campaigners made sure he could take care of himself so Joe wouldn’t have to.

Joe gets back in his car for the ride home, and turns on a radio talk show. The radio host keeps saying that government involvement in our lives is bad and the less government involvement in our lives, the better. The host doesn’t mention that those who rail against government have fought against every protection and benefit Joe enjoys throughout his day. Joe agrees with the host and really believes the following which he espouses from time to time: “We don’t need big government ruining our lives! I just stay uninvolved. I never participate in this sort of hogwash. I don’t vocally or financially support any public policy issues. I don’t feel the need to get involved in those political types of things whatsoever because —— After all —— I’m a self-made man who believes everyone should take care of themselves, ———— just like I did ————.”

“The bottom line for all of us is, we must do everything we can to enhance our political giving practices. Currently, practitioners, about 40,000 contribute an average of $3 per year for this purpose. We would all agree that number is pretty pathetic.”

Some of you may know a psychologist who believes as Joe does. The truth is that by the year 2018, 50% of health care will be paid for by the government if all things were to remain the same. In 2009, $2.5T will be spent per year on health care. Next year, 18% of GDP will be spent on health care. This is to say that it is no wonder why health care reform has been such an incredibly difficult industry to change. There is a lot of money floating around in the system and a lot of interests that are unwilling to modify their practices, their share of this almost $3T industry, simply because their stake in it is so very lucrative.

While it is true that Psychology has done better in representing our own interests and those of our patients over the past decade, we made some terrible mistakes in the distant past, one of which took us 25 long years to rectify. I am referring to the time we opted out of the Medicare Program in the mid-60s. How brilliant was that?????

Let me throw a couple of other facts out for you to consider if there is anyone that doesn’t think money is a powerful determinant in the US election process, an area of particular weakness in psychology’s advocacy program. All of us are aware that Barack Obama raised a ton of money last year in his presidential run. The myth is that he did so with an equal number of small contributions as large ones. In reality, Obama raised 80% more from large donors than from small ones, outstripping all rivals and predecessors (small donor being defined as a contribution of less than $200). The amount of money that poured into all federal elections in 2008 was staggering, more than $6.3B. The total directly raised in Congressional races alone in 2008 was $1.3B.

That being said, let me preface my next remarks by saying that I do not intend them to be construed in any way as an endorsement of the current campaign finance system. I do want to convey, however, my strong belief that if we want to achieve even a modicum of success with our legislative agenda here in Washington, we must recognize that the current system of campaign finance IS the coin of the realm. And, no matter how much we may disapprove of it, it is the system that dominates elections and I believe it will continue to do so for a long time. I believe that for one simple reason. Those people that would have to change the law, members of the US Congress, are the same people that benefit enormously by NOT changing the law in any appreciable way. Incumbents win elections at the federal level with an over 90% success rate. They overwhelmingly can raise far more money than their challenger opponents. Let me ask you, would you change a system that was so heavily weighted in your favor????

The bottom line for all of us is, we must do everything we can to enhance our political giving practices. Currently, practitioners, about 40,000, contribute an average of $3 per year for this purpose. We would all agree that number is pretty pathetic. If we raised the average contribution to only $25 per year, psychology would have the second largest PAC in the health care industry, excluding the pharmaceutical companies. You can do your share by both contributing to AAP and informing your colleagues about the value of doing so. Visit the AAP website today and make a contribution and urge your friends to do so too: www.aapnet.org.

Spring 2009 Newsletter

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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.

Winter 2009 Newsletter

I am writing this column in the middle of the most surreal Republican Convention of my lifetime, which follows on the heels of the historic Democratic lollapalooza Convention just a week ago. But nearly as interesting, though less widely acknowledged, is a political story that may turn out to be even more central to the theme of change which dominates both Presidential campaigns. I am referring to the intense battle being fought currently by Democrats to win both a filibuster-proof Senate majority and increase the Democratic majority in the House at the polls in November

To be sure, there are some great House and Senate races to consider and keep an eye on over the next two months. And, there are so many questions to consider. Will Republicans win back House seats they lost due to scandal (e.g., Mark Foley) in 2006? Will Obama be that much of a boost to House and Senate races for the Democrats? Can the Democrats reach the magic number of 60 in the Senate?

Starting with the Senate, Democrats know this is a huge prize, and they are throwing nearly as much money and sweat into that effort as they are into electing Mr. Obama. What isn’t clear is whether voters are as aware of the stakes. An unstoppable Democratic Senate has the potential to alter the balance of power in Washington in ways not seen for many moons.

For background, here are the raw numbers: Republicans must defend 23 seats, compared to only 12 for the Democrats. Of those GOP slots, 10 are at potential risk: Virginia, New Mexico, New Hampshire, Minnesota, Oregon, Colorado, Alaska, Mississippi, Maine and North Carolina. The Democrats claim only one vulnerable senator this year, Louisiana’s Mary Landrieu who has been a close friend to psychology during her tenure in Washington. Depending on how big a day the party has in November, it is at least conceivable that Democrats could get the nine seats they need to hit the magic 60 mark.

Of note, if this situation came to pass, it would not be the first time. At least twice before, the Senate has been in this filibuster-free condition. Both times they went on a spending spree. FDR passed his New Deal and Lyndon Johnson passed his Great Society with filibuster-proof majorities.

Today, however, partisanship in Congress is not only more pronounced, but it is also much more cohesive than in days of old. According to Congressional Quarterly, in 1994 Senate Democrats voted with their party 84% of the time. By 1998, that number was 86%. CQ’s most recent analysis of votes during the George W. Bush presidency, showed Democratic senators remained united 91% of the time. Should he get his 60 seats, Senate Majority Leader Harry Reid (an AAP Black Tie Honoree) will be arguably more influential than the president.

60 votes still aren’t enough to override a presidential veto. But a filibusterproof majority would put Mr. Reid in almost complete control of the agenda. That holds equally true whether we have a President McCain or a President Obama.

Interestingly both Obama and McCain are touting their bipartisan bona fides in selling their candidacies to voters. In reality, however, if a filibuster-proof senate becomes a reality, presidential standing will be of lesser concern. A Democratic Senate with 60 votes will rule the day and the very senior committee chairmen in the Senate, fairly full of themselves now, will undoubtedly pounce on the new more expansive opportunity to exert their power with or without the President’s consent. Remember, power is the currency that matters most in Washington. Calling the shots and demonstrating who is in charge is the sine qua non in the power game.

Keep in mind also that Mr. Reid won’t necessarily need 60 Democratic votes to reign supreme in Washington. There is still a small contingent of moderate Republicans like Olympia Snowe and Susan Collins who don’t always vote party line. Mr. Reid could fend off a filibuster even if the Ds win only 57 or 58 seats.

You may have noticed that much legislation is in a holding pattern of late. Congressional Democrats are not moving much in the way of spending bills, energy bills, or anything at all really. They are waiting for next year when they think the prospect for producing bullet proof majorities in both houses is quite favorable.

With a filibuster-proof majority, for example, Democrats could reshape the judiciary under a President Obama, or refuse to confirm any Antonin Scalia-type appointments made by a President McCain.

Fall 2008 Newsletter