AAP Newsletters

Medicare is scheduled to reduce its payments to psychologists and other health care professionals by a whopping cumulative amount of twenty-five percent by the year 2011 if legislative action fails to avert the cuts. That is real money from anyone’s perspective. What makes this news even more startling is that at the same time cuts for providers are being planned, a windfall has been awarded to the pharmaceutical industry in the form of the major Medicare Bill passed in late 2003 and heralded as the most comprehensive reform of the Medicare system since its inception forty years ago. The most significant and costly part of the new Medicare law is the inclusion, for the first time, of drug benefits for seniors. One does not have to drill too deeply into the law to discover that the drug benefit is actually little more than a huge gift to drug companies wrapped in the flimsiest of tissue paper.

You may be asking how this could happen when the U.S. healthcare system as a whole seems to be on the brink of disaster as costs soar every year. I will attempt to answer the question of how this happened, but first let me cite a few data points to underline the proposition that the new law is little more than a payday for the drug companies. First, instead of lowering drug prices for seniors, many reputable sources indicate that the reverse will occur. Seniors may not see cheaper prescription prices when the new Medicare plan is fully implemented in 2006, because it does nothing to control the rising cost of drugs. According to Consumers Union, “most beneficiaries will face higher out-of-pocket costs for prescription drugs after full implementation, despite the benefit.” In addition, drug manufacturers have been raising prices in anticipation of a Medicare discount plan, negating potential savings from discount cards.

Wholesale prices for popular brand-name prescription drugs rose an average 7.1% in 2004, just slightly higher than the 7% price rise in 2003, and more than twice the general inflation rate, a study commissioned by AARP said. The findings come from an examination of prices charged by manufacturers on 195 brand-name prescription drugs widely used by Americans 50 and older. The study’s authors said such increases are routinely passed on to consumers in retail prices.

According to House Government Reform Committee, Minority Staff, the prescription drug benefit is so bad that seniors can pay less over the internet, with price negotiation or from buying drugs from Canada. The prices for drugs commonly used by seniors like Lipitor, Prevacid, Zocor and Aricept are all cheaper from Drugstore.com than with the Medicare prescription drug card.

According to the Minnesota Attorney General’s Office, “[T]he pharmaceutical industry has been the most profitable industry in the United States for each of the past 10 years. In 2001, it was 5-1/2 times more profitable than the average of all other Fortune 500 companies.”

Most astonishing is the fact that the legislation explicitly PROHIBITS Medicare from directly negotiating drug prices with the pharmaceutical industry, an effective cost control solution in place for virtually every other major provider of Medicare services. The provisions will add an additional $139 billion to the cost of the bill over the next eight years in increased drug industry profits, according to the Medicare Rights Center. This provision alone qualifies the legislation as the mother of all sweetheart deals.

The above background information serves to underscore the conclusion that something is rotten in Denmark. How was such a sweetheart deal struck? Much of the answer lies in a predictable five letter word, MONEY.

Even a cursory examination into the way the pharmaceutical industry controls health care policy by buying influence at the highest level of government, and underwriting professional and lay healthcare organizations whose spokespersons parrot the industry’s agenda yields a rich portrait of the power drug companies exert on Capitol Hill.

Of the 1,274 people registered to lobby in Washington for drug makers in 2003, according to the Center for Public Integrity, 476 are former federal officials — including 40 former members of Congress. This is the epitome of “inside baseball.”

The Pharmaceutical industry spent a total of $158 million in 2004 to lobby the federal government and an additional $17 million was disbursed in campaign contributions in 2004 to federal candidates (67% to Republicans). By contrast, the American Medical Association spent a measly $2 million over a two year period ending in 2004, and AAP spent around $200 thousand. Add to these amounts a staggering $7.3 million in support for the 2004 political party conventions (64% to Republicans) and you have the makings of the most powerful lobby on Capitol Hill.

Without a doubt, the pharmaceutical companies are together one of the strongest, most well-connected and most effective lobbies in Washington. Going up against them is more often than not a losing battle. But lobbyists aren’t the industry’s only voice. When witnesses lined up last Spring for a Senate hearing on the FDA’s drug-approval process, no representative from the pharmaceutical industry was present. But at least three witnesses on the sixmember panel were from groups that get money from drug makers

Perhaps worse than the industry’s official lobbyists, are the industry’s “friends” who masquerade as patient advocacy groups. A story about the industry in USA Today quotes Nancy Davenport-Ennis, who heads the National Patient Advocate Foundation (NPAF). She was the leadoff witness in the Senate hearing about Vioxx and the other painkillers, warning against any “overemphasis on safety.”

It appears to me to be a bit unseemly when a “patient advocacy” group worries more about delay in availability of new drugs—rather than their safety. While not a slam dunk, I’d say this provides reasonably good data to conclude that the NPAF and groups like it are in bed with the pharmaceutical industry. When confronted about her organization’s funding sources—e.g., Pfizer, Merck and GlaxoSmithKline—Davenport- Ennis told USA Today, “the drug company grants come with no strings attached and amount to ‘a whole bunch less than half’ of the group’s budget. I don’t think there is a patient-advocacy group in America that does not receive some level of funding from a pharmaceutical company.” Therein lies one of the problems.

The pharmaceutical industry has more than demonstrated that it knows politics as well as it knows chemistry. The short list of their recent successes includes: winning coverage for prescription drugs under Medicare in 2003 while blocking the government from negotiating prices downward, so far they have kept out imports of cheaper medicines from Canada and other countries, and they have protected a system that uses company fees to speed the drug-approval process.

In the end, drug makers are fully dependent on the federal decisions made by Congress. The government determines almost every aspect of how a drug gets into a consumer’s hands. Not only that, but the government buys massive quantities of drugs through Medicaid, the Veterans Administration and other programs. Once the new Medicare prescription drug benefit takes effect in 2006, the government will be paying 41% of Americans’ drug bills, up from 24% now. It’s hard to imagine any group doing better than this industry does with the government.

It is eminently reasonable to conclude that the industry wins more in Congress than they should. And it’s not hard to understand what the main ingredient of their winning strategy is. The one really big thing they have going for them, as stated above, is MONEY.

I know that many psychologists are prone to wring their hands and complain about how awful it is that legislation can be infected by the infusion of political money. I don’t disagree with their complaints. I do know, however, that the situation is not going to change anytime soon, regardless of how many campaign finance laws may be introduced. So if we psychologists are realists/pragmatists and can put our idealist aspirations on hold, we must play the advocacy game within the system as it currently exists with its emphasis on money.

Psychology will never have the kind of money to throw around that drug companies do. That goes without saying. The point of this column is to emphasize, once again, that money matters in Washington, perhaps more than it does in many other places. While psychology can never hope to reach the lobbying heights of the drug-industrial complex, we CAN do far better than we have done to this point. The fact that you are reading this column indicates that you are probably doing your part to contribute. I ask that you consider contributing one additional item to the profession, and it doesn’t involve your checkbook. I urge you to educate your uninformed colleagues about the critical need to get involved in political advocacy for psychology. Ask them to become members of AAP, and don’t take “no” for an answer. Ask them to contribute to AAP/PLAN, and don’t take “no” for an answer. The only way our clout will grow in the halls of Congress is by this kind of personal appeal to our non-participating colleagues. It doesn’t take much to make a difference. If every AAP member would recruit just one colleague, it would make a very substantial difference in the way psychology is perceived on Capitol Hill. Recruiting involves educating at least one colleague about the importance of joining AAP and/or contributing to AAP/PLAN, and then “closing the deal” by obtaining their commitment with a follow-up contact to insure that they have fulfilled that commitment to you. On the one hand that is asking a lot of you I know, but on the other hand it is the least we can all do to insure that psychology will have voice in Washington. Please commit to do this today

Summer 2005 Newsletter

The highlight of last summer’s Democratic National Convention in Boston, in my mind, was the moving speech delivered by then candidate and now Senator Barack Obama (D-IL). Obama is a truly gifted individual whose powerful portrayal of America in the context of the polarized zeitgeist of the times in which we are living was captivating.

Here is a snippet of what he said.
“Now even as we speak, there are those who are preparing to divide us, the spin masters and negative ad peddlers who embrace the politics of anything goes.
Well, I say to them tonight, there’s not a liberal America and a conservative America —there is the United States of America.
There’s not a black America and white America and Latino America and Asian America —there is the United States of America.”

In that context, among psychologists as a group, there is also a wide diversity of interests, of beliefs, of disciplines, of theories of psychology, of therapeutic modalities, and so on. However, as psychologists we all share at least one thing in common—We are members of the same family by virtue of the fact that we share the same common family name, PSYCHOLOGIST.

That is one of the primary reasons why the Association for the Advancement of Psychology, the only national psychology organization operating a Political Action Committee, represents ALL of psychology, and not just the interests of liberal psychologists, or conservative psychologists, or male psychologists, or female psychologists, or analysts, or behaviorists, etc… AAP represents Psychology, period. And to be at all effective in representing all of psychology’s interests, we must develop and nurture relationships with members of Congress, regardless of their party affiliation, who are willing to support psychology’s legislative agenda.

At the 2004 State Leadership Conference, Crossfire Co-host, Paul Begala, asked how many of those in attendance at a plenary session were Democrats and how many were Republicans. I was sitting on the dais next to Congressman Tim Murphy, a staunch Republican. I remember his audible groan when the vast majority of hands raised in the room indicated that most in the room were Democrats.

Despite the fact that the majority of psychologists identify themselves as Democrats, can psychology’s PAC afford to support only Democrats running for office?To answer that question, of course, you must keep in mind that for the better part of the last decade, Congress has been controlled by Republican majorities and most political pundits predict that this situation is not likely to change in the foreseeable future.
It is true, I think, that many psychologists have a difficult time accepting the concept of providing campaign support to Members of Congress who are affiliated with the “OTHER” party. Actually, if our contributions are an accurate indicator, we can safely say that psychologists have a hard time accepting the fact that contributing money to a psychology PAC, regardless of party, is a concept which is difficult to get their arms around, or more precisely, difficult to get their hands out of their pockets to support.

Let me provide you with some psychology-specific anecdotes, however, that I think will put a fine point on this matter. You may recall that in 1996 the historic mental health parity bill was first passed in the Senate. The bill would have never seen the light of day had it not been for the efforts of New Mexico Republican Senator Pete Domenici joining with the late Paul Wellstone to champion that historic piece of legislation. Both these men, by the way, have been honored at one of AAP’s Black Tie Dinners.I’ll never forget the impassioned pleas made by conservative Senators Alan Simpson (R-WY) and Orrin Hatch (R-UT) on the floor of the Senate when they told personal stories about how devastating mental illness has been in the lives of their loved ones and then they asked for their Senate colleagues’ support of the bill.

Some may remember that in 1995, psychiatry had succeeded in convincing House Armed Services Committee member Bob Dornan to terminate the Defense Department’s Demonstration Project which was training military psychologists to prescribe psychotropic medications. At the time, there were a handful of military psychologists who were in the middle of their extensive training. Had the program been killed as was then planned, those psychologists would have wasted years of effort and training. Republican Congressman Duke Cunningham (R-CA) was asked for his support to oppose the program’s termination. He not only agreed to stand up for the program and psychology, but also agreed to enlist other Republicans’ support. This was a critical turning point in saving the program because the Republicans were in control of the Armed Services Committee. This action allowed for the continuation of the demonstration project and the psychology trainees were able to complete their training.

I would venture to say that New Mexico’s and Louisiana’s success in obtaining prescribing privilege legislation would not have been possible had it not been for the success of the 10 military psychologist prescribers. Today those military prescribers provide critically needed data to counteract the scurrilous attacks being made in state after state by psychiatry which allege that psychologists will do untold harm to the public if they are allowed to prescribe. Our military trained sample of 10 psychologists can stand up and unequivocally say there is not one shred of evidence during the 10 years of their functioning as military prescribers to support this fictional allegation.

March 2005 AAP Black Tie honoree, Senator Mike DeWine (R-OH), has worked very closely across the aisle with Congressman/psychologist Ted Strickland (D-OH). Ted describes the two as having a very strong work relationship. They have successfully passed two very important pieces of legislation together which have had an impact on psychology, the Mental Health Courts pilot project enacted in 2000, and the Mentally Ill Offender Treatment and Crime Reduction Act, enacted in October 2004.
Back in 1995, psychologists might be surprised to learn that AAP/PLAN made a small contribution to ultra-conservative Senator Jesse Helms’ campaign after he vigorously backed changes in Medicare that were very beneficial to psychologists. At an AAP Black Tie dinner honoring liberal Senator Tom Harkin a year later, Harkin said, “it is a tribute to how far psychology has come on Capitol Hill that Tom Harkin would EVER co-sponsor a bill with Jesse Helms.”

Bipartisanship in the legislative advocacy arena is not a luxury, it is a necessity. Even though Republicans enjoy a 55 to 45 majority in the Senate, they must rely on picking off at least five Democrats if they ever intend to invoke cloture which is needed to end a filibuster. This rule makes passing controversial legislation very problematic in the Senate without bipartisanship because Senate rules require a supermajority of 60 votes on some critical matters like cloture votes.

If psychology’s thinking and our political strategy had historically been dominated by those who believe that we should support only those who share our political ideology about every matter from gun control, to abortion, to the arctic wildlife preserve, careers for psychologists would be very simple and highly limited today. We would all be restricted to a very narrow range of practice that would not reach much beyond administering the Stanford-Binet with a smattering of teaching thrown in. Of course, the boundaries that would dictate such a strait-jacket on practice would be the result of having been legislatively shut out from providing the wide and rich array of services we now provide to the public. Can anyone deny that we now enjoy the fruits of our elder psychologists’ labor? We enjoy being INDEPENDENT providers of services with no need for psychiatric supervision, we benefit from freedom of choice legislation requiring insurance companies to recognize psychologist providers of mental health services, we have all benefited from inclusion of psychologists in the Medicare Program, and on and on and on. These illustrations only scratch the surface of what legislative action and vision has generated for psychologists.

Always remember, none of these gains would have been possible without the support of legislators from both sides of the aisle.

Spring 2005 Newsletter

Despite the fact that President Bush won a clear victory, Election 2004 did not cause a major shift in the tectonic plates of our political system as some have tried to describe it. Two years ago the Almanac of American Politics used the term, “49-49 nation” to characterize the election deadlock we experienced then. Using that same terminology, we are a “51-48 nation” today. To be sure this reflects movement, but it’s not even close to being a fundamental alteration of the country’s political alignment.

True, two states moved from Blue to Red (Iowa and New Mexico), while New Hampshire went from Red to Blue. Ohio maintained its red status but did so by a hair in changing to “light red”. Many have noted that a 60,000 vote shift in Ohio would have produced a Kerry presidency. Put another way, the election may be seen as having pivoted on 119,000 votes in Ohio out of 120 million votes cast nationwide.

Republicans can be proud of their four-seat gain, but their sense of accomplishment should be tempered with the recognition that every one of those gains was in a state that Bush carried in both 2000 and in 2004. Again, this hardly speaks to a conversion experience. It more accurately reflects the continuing rearrangement of the South. Of note, only two southern Democrats are left in the Senate: Blanche Lambert Lincoln of Arkansas and Mary Landrieu (a recent AAP Black Tie Honoree) from Louisiana.

Even in the House, it was only because of the redistricting in Texas that Republicans gained three seats rather than losing two. And, in state legislatures, Republicans decreased their margin from having a 64 seat advantage nationally to having a 12 seat deficit.

At the end of the day, this election was hardly one upon which a revolution in policy can be based. Many liberal leaning psychologists, whose numbers are high, appear to be grief-stricken by the outcome of the election. More conservative professionals, needless to say, are quite pleased with the results. The numbers don’t lie, though. Neither liberals, nor conservatives should make more of this election than the fact that it was a small shift in course. It clearly did not chart a whole new direction.

All the pundits have weighed in with a host of reasons for this election’s outcome. Prior to the election, we were bombarded with predictions about how important “get out the vote” efforts would prove to be. Democrats did an amazing job of getting their vote out, but Republicans did even better. In the battleground states, Democrats pulled in the number of votes that they thought were sufficient to win, yet failed to match Republican totals.

Turnout in the12 swing states increased 17.3 percent, from 31.2 million in 2000 to 36.6 million in 2004. In the strong-Bush states it increased 14.9 percent from 37.6 million in 2000 to 43.1 million in 2004. Yet in the strong-Kerry states, turnout rose only 1.9 percent, from 36.6 million to 37.4 million. While it’s true that these differences did not have an impact on the electoral vote, it likely explains Bush’s 3.5 million popular-vote advantage.

It’s very easy to play Monday morning quarterback and cast aspersions upon Kerry’s “flawed” strategy. Students of political science and presidential elections will have much to mull over during the next few months. Kerry certainly can be rightfully criticized for allowing too much of the campaign to be dominated by the war in Iraq and not directing nearly enough attention to the economy. It is also safe to say that Kerry talked too little about another serious vulnerability for Bush, health care. Healthcare was critical, not only because of its inherent importance to the welfare of the country, but also because of its importance to the largest block of voters.

Surely all psychologists would agree about the critical importance of reforming the nation’s health care, but in the context of the election, NOT talking about health care may have suppressed potential votes from one of Kerry’s most vital constituencies, women. The “women’s vote” constitutes the single largest voting block nationally. It is larger than the moral conservatives vote, the NRA, or any other interest group. Both the women’s turnout and Kerry’s share of women’s votes decreased in 2004. Women normally comprise 51 percent of the national vote; this time they were 49 percent. Bush carried the male vote by 11 percent, and Kerry won among women by 3 percent. This was significantly down from Al Gore’s 11 point margin in 2000.

Health care is an issue about which women care very deeply according to every national poll. Let’s hope that candidates from both parties will begin to recognize the real importance of focusing on health care in 2008. However, even if they won’t recognize the REAL need for health system change, let’s hope future candidates will at least appreciate that they need the support of women to turn out to vote for them. One way to accomplish this is to include women’s concerns about health care prominently and compellingly in one’s policy agenda. There is more than one way to skin the cat, as they say.

While security may have been the highest priority for voters at the polls in 2004, ignoring the health care issue or underestimating its importance in relation to the largest block of voters may have been a key reason in determining defeat in 2004. 2008 will offer two fresh candidates (although Kerry may get a second chance) another opportunity to focus on healthcare. Between now and then, psychologists must continue to work diligently to insure that mental health care is seamlessly integrated into the overarching health care system in the minds of lawmakers. We have made great progress in this regard, but there is much work left to do.

Winter 2005 Newsletter

Last March, Paul Begala, co-host of CNN’s Crossfire, asked audience members, during his keynote speech at the APA’s State Leadership Conference, to indicate their political party affiliation by a show of hands. The vast majority, not surprisingly, were Democrats. Know that, however, even though most psychologists are Democrats, AAP/PLAN has no choice but to function in a bi-partisan fashion if psychology is to have any hope of being effective in Washington. This is a tall order given the contentiousness, animosity and downright hostility that exists between the two parties at this critical juncture in the political world.

When audience members raised their hands during Begala’s presentation, I was sitting next to psychologist Tim Murphy, a partisan Republican member of Congress. I could sense his blood begin to boil when the lopsided number of Democrat hands were raised. Tim’s reaction reflects powerful feelings that are held about the political parties’ contrasting approaches to governing, public policy, the economy, defense, and certainly health care.

This is an extremely important election year. There is so much at stake when voters go to the polls in November. What leads Americans to become attached to and ultimately identify with being a Republican or Democrat? Psychologists may be best able to shed some light on revealing what factors underlie that choice of aligning with one or the other political party and the adoption of conservative or liberal political ideologies. There has been some unusual research in this area recently that you may find interesting.

Just a few months before retiring from public office in 2002, the House majority leader Dick Armey caused a mini-scandal when he announced during a speech in Florida, ‘’Liberals are, in my estimation, just not bright people.’’ The former economics professor went on to clarify that liberals were drawn to ‘’pations of the heart,’’ while conservatives favored ‘’occupations of the brain,’’ like economics or engineering.

Armey was never a stranger to controversy during his long service in the House. However, his statement was far from being the sort of logical and rational kind that good Republican brain-dominated, according to him, speakers would articulate. In fact, it displayed a fuzzy, unscientific understanding of the brain itself. Of course, psychologists are fully cognizant of the fact that our most compassionate (or cowardly) feelings are as much a product of the brain as ‘’rational choice’’ economic theory is. Our neuropsychologist colleagues tell us they just emanate from a different part of the brain — most notably, the amygdala, in the limbic system.

As it happens, some early research suggests that Armey might have been on to something after all. A team of U.C.L.A. researchers analyzed the neural activity of Republicans and Democrats as they viewed a series of images from campaign ads. And the early data suggested that the most salient predictor of a ‘’Democrat brain’’ was amygdala activity responding to certain images of violence: either the Bush ads that featured shots of a smoldering ground zero or the famous ‘’Daisy’’ ad from Lyndon B. Johnson’s 1964 campaign that ends with a mushroom cloud. Such brain activity indicates a kind of gut response, operating below the level of conscious control.

Imagine that the research reveals that liberal brains have, on average, more active amygdalas than conservative ones. After all, this would reflect the conventional wisdom about liberal values: an aversion to human suffering, an unwillingness to rationalize capital punishment and military force, a fondness for candidates who like to feel our pain.

Opening up the brain might provide new explanations for how people become Republicans or Democrats. It’s pretty naive to think that we all decide our political affiliations by methodically studying each party’s positions on the issues. A recent study by Paul Goren at Arizona State found that voters typically formed their party affiliations before developing specific political values. They become Democrats first and then decide that they oppose capital punishment and support trade unions, for example. But how do they make that initial decision to be a Democrat? The most likely indicator of political preference is ones parents’ party affiliation. However, if everyone voted along family lines, the dominant party would simply be the one whose members had the most voting offspring. A more interesting question is why someone would ever break from the family tradition — without feeling strongly either way about specific issues.

The M.R.I. research suggests that perhaps we form political affiliations by semiconsciously detecting commonalities with other people, commonalities that ultimately reflect a shared pattern of brain function. In the mid-1960’s, social psychologist Donn Byrne conducted a series of experiments in which the participants were given a description of several hypothetical strangers’ attitudes and beliefs. They were then asked which stranger they would most enjoy having as a co-worker. The subjects consistently preferred the company of strangers with attitudes similar to their own. Opposites repel.

If you’re inclined to form strong emotional responses to images of violence or human suffering, and over the course of your formative years, most of the people you meet who respond to these images with comparable affect turn out to be Democrats, it may produce a commonality of experience. This is likely to be closer to a gut instinct than a rational choice, but if you meet enough Democrats who share that experience, sooner or later you may start carrying the card yourself. This theory suggests that political identity starts with a shared temperament and only afterward deposits a layer of positions on the issues.

Seeing political identity as a reflection of common brain architecture helps explain another longstanding riddle: why do people vote against their immediate interests? Why do blue-collar Republicans and limousine liberals exist? The question becomes less puzzling if you assume that: 1) people choose parties primarily because they desire the companionship of people who share their cognitive wiring, and 2) they desire that companionship so much they’re willing to pay for the privilege.

If the U.C.L.A. results hold water over time, it won’t justify the Armey theory that liberals are somehow less rational than conservatives. For 20 years we have known that the brain’s emotional systems are critical to logical decision-making. People who suffer from damaged or impaired emotional systems can score well on logic tests but often display markedly irrational behavior in everyday life.

Speaking of logic, once we psychologists uncover the mystery of political affiliations, it would behoove us to examine the variables underlying voting behavior. Despite the vitriol displayed by each political party toward the other, Americans as a whole, for the most part, opt out of the electoral process In the 2000 Presidential election, for instance, only around 100 million voters turned out. This number represented about 50% of the total voting age population in this country. Further, more than 50 million registered voters chose not to vote. Surveys indicate that the vast majority of these non-voters cited that they were too busy, not interested, or were out of town.

The U.S. is currently engaged in a war attempting to bring Democracy to the Middle East. The fact that 50% of Americans, living in a country founded on the principle of democratic voting rights among others, choose to sit at home on election day is rather astonishing. While we are in the process of studying brain activity, let’s take a look at the very questionable brains of those folks who don’t exhibit enough interest in public policy to even participate at the most basic level of the electoral process, voting.

It is reasonable to ask, “is there something intrinsically reductive or fatalistic in connecting political values to brain functioning”? No more so than ascribing them to race or economic background, which we happily do without a second thought. No one denies that social conditions shape political values. But the link between the brain and the politics is still uncharted terrain. Much has been learned in the past decade about the relationship between biological factors and emotions. It has also been demonstrated that psychotherapy in combination with psychotropics provides the most potent intervention for treating emotional disorders such as severe depression. Perhaps the next generation of AAPers will be devising ways to impact the public’s party affiliation choices at an emotional level. For the time being though, we must keep plugging away at increasing psychology’s profile on Capitol Hill by expanding our political influence through AAP and AAP/PLAN working in conjunction with the APA Practice Organization.

Fall 2004 Newsletter

It is always tempting, with a presidential election only months away, to speculate about the outcome of that quadrennial event. Given what appears to be a fairly even political divide in this country, the smart money is betting for a photo finish much like the one we witnessed in 2000. Hopefully there will be no court involvement this time around. Keep your eyes on three battleground states: Ohio, Pennsylvania and Florida. It is likely that they, and perhaps only a handful of others, will decide who the next president will be.Of equal importance, at least to psychologists, is the question of what the future looks like with regard to the mental health service system. Ergo, my reference above to the Sergio Leone classic starring the former Mayor of Carmel, California, Clint Eastwood, entitled, “The Good, the Bad, and the Ugly”.

I’ll start with the ugly. It’s no secret that mental health services have been cut more than most health care specialties over the past decade. Under the knife of managed care companies (MCOs), reimbursement rates have been slashed and access to psychology services has been increasingly restricted. The facts are undeniable: mental health care gets just 1.6% of the total health insurance dollar today. That’s according to Joan Pearson, a behavioral health specialist with the consulting firm Towers Perrin, which develops employee benefits packages for large corporations nationwide. And that figure is trending downward: In the late 1980s, the number commonly quoted was 9%. And as recently as 1997, we heard estimates as high as 5%. Keep that in mind as you consider what follows.

Since employers and the federal government are the two dominant forces determining health insurance benefits in this country, it is reasonable to ask, “what do employers want?” The acronym now being used by consultants and managed care companies is — CDHP — that’s “consumer driven health plans.” Under a CDHP scenario, an employer contributes a fixed dollar amount each year—most likely into a worker’s medical savings account (MSA). One option a worker can pick is coverage with high deductibles which, when met, trigger a catastrophic illness provision under extraordinary conditions.

This is not some sort of futuristic concept — it’s already here, to some degree. A trend-setter in this area is the federal government, which has been offering versions of CDHPs through the Federal Employee Health Benefits (FEHB) program. The government is attempting to facilitate CDHPs in order to engage the consumer more directly in health care purchasing decisions. It’s only a matter of time, and probably a short period at that, before corporate America offers CDHPs as the latest way to sustain the faltering current patchwork health care system which is gasping on its last breaths.

You better believe that CDHPs will affect mental health benefits more than other sectors of health care. Imagine a patient with a $1,000 deductible. That individual is likely to be reticent to seek ANY kind of health care, but it’s very likely that he is going to be even more reticent to seek mental health care.

On the positive side of the ledger, stigma about mental health care has been going down. But until now, consumers have been shielded from the true costs. What’s going to happen with the advent of CDHPs is that there will be an initial amount of money (a relatively large amount) consumers are going to be paying for their deductible, and only after that amount is met will their insurance coverage kick in. When it comes to mental health, the system will in essence be like a catastrophic coverage plan. It seems clear that companies are going to offer these plans, but they will probably be offered as an option among many plans. In my view, the best outcome for these will be if consumers respond to them like they did to the original 1996 MSA law. If so, consumers simply won’t choose them.

Even if CDHPs become widespread, many practitioners will be largely unaffected by them. Those who have developed specialties that a broad section of the public understands, and perceives the need for, will most likely experience little if any change in their practices. Areas where there are unmet needs, for instance, are not likely to be touched. These include the treatment of chronic pain, and heart disease-related depression, for example. The whole set of disease management issues is likely to be a growth area. Surveys show that health plans are focused on depression. Look for a proliferation of depression initiatives in medical settings.

The need to increase our efforts and our political giving is clear. We can’t afford to reduce the pressure on members of Congress to enact legislation to protect patients.

In this context, we know depression is a leading cause of morbidity in cardiac disease. The Practice Directorate, by the way, is undertaking a large congressionally supported Medicare demonstration project which will be examining the relationship between psychological interventions and cardiac illness (see Advance Fall 2003, page 13). It is known that 40% of the morbidity in cardiac disease is driven by undetected depression. You can bet that this is an area where you’re going to see a heck of a lot of activity and innovation.

The one question that is easily the most compelling for psychologists is, “Is there any relief in sight in the area of MCO reimbursement rates”? Regrettably, I wouldn’t plan on it. All psychologists in the trenches know what a beating reimbursement rates have taken. Some companies butchered provider rates over the last several years. The only good news in this area is that most probably the worst is over. There is at least one potentially positive occurrence in the realm of reimbursement, a pilot program that offers bonuses to Magellan providers who deliver “better quality care” to members. Consideration is currently being given to expanding that program to other markets.

The second biggest concern psychologists have about their practices is the deluge of administrative busy work foisted upon them by MCOs. Cigna recently eliminated the onerous Outpatient Treatment Report (OTR). Could this move by a major MCO indicate that other companies will follow suit? There is a reasonable probability that such a move by other companies will occur, not because they see the error of their ways, but because the employers who purchase the plans are going to drive the show and they all want to cut costs. Eliminating OTRs is a good way to reduce costs. Believe it or not, there is still concern among employers over inpatient treatment costs, and they may be willing to cover additional outpatient care to further curtail the inpatient side. This reasoning should sound familiar to those of you who can still remember the early 90’s. It is the very argument that organized psychology made in 1993 when the Clinton Health Security Act was being formulated. At that time, psychology successfully convinced policy makers that an unlimited outpatient mental health benefit would be a win/win for everyone. Outpatient benefits appear to be back in favor with MCOs. We have always accused them of being a bit sluggish cognitively, now here’s confirmation for that contention.

The last item in the crystal ball pertains to our old friend, “outcomes measurement.” MCOs have paid lip service to measuring the effectiveness of therapy; but never really did anything about it. Instead, they’ve kept employers happy by slashing fees, restricting access, and cutting treatment length. However, employers are increasingly demanding accountability, wanting proof that their purchases of mental health services actually provide a tangible return on their investment. One MCO, PacifiCare, is using a self-administered 30-item questionnaire at intervals during treatment. Clinicians are responsible for collecting the forms and faxing them in. Other major MCOs, including CIGNA and UBH, continue to use a variety of assessment tools. These could be good news. However, the jury’s out on these at this juncture.

All of the above potential developments point out how critical the role of political advocacy is to the profession. The need to increase our efforts and our political giving is clear. We can’t afford to reduce the pressure on members of Congress to enact legislation to protect patients. Although we are guardedly optimistic about passage of the Wellstone Mental Health Equitable Treatment Act, for instance, we can’t allow this issue to fade, even for a moment. Senate Minority Leader, Tom Daschle has been a great friend to psychology who was recently honored at an AAP Black Tie Dinner (see story about this on the Movers and Shakers page 8 in this Advance). Although we have cultivated many other friends like Senator Daschle, we must do more. Please take an active role in doing more. Persuade a colleague to join AAP today (it’s easier now than ever. Refer your recruits to AAP’s online application at www.aapnet.org).

Spring 2004 Newsletter

I was an audience member for the first televised California Governor’s debate last Fall. Although Arnold skipped that debate, one of the candidates clearly stood out. Some called her a pest, others called her annoying, and many called her self-promoting. She was certainly entertaining, added spark and spice to all the debates, and persistently held the feet of the other candidates to the fire when the moderator refused to do so.

From my perspective, Arianna Huffington’s candidacy, despite the fact that it had almost no chance for success, played a major role in the California Gubernatorial campaign. She, and no one else, articulated and accentuated an issue most candidates don’t dare touch: the corrupting influence of California’s political contribution system. I won’t forget the look on Lt. Gov. Cruz Bustamante’s face when Ms. Huffington accused him of “legalized bribery” for accepting barrels of money from special interests, like Indian casinos. Aside from the shock value of the moment, her characterization was an honest, no-holds-barred, accurate description of what was going on in California and in many other elections across the country.

What do California’s campaign financing mechanisms have do with psychology’s federal political action program and AAP? The answer is, “absolutely nothing.” This is precisely my point. Psychologists must understand, in no uncertain terms, that the kinds of campaign support activities in which AAP engages are in no way related to the sorts of corrupting special interest influences that are commonly bandied about by the press and by politicians. Psychologists must be able to distinguish the sort of access to legislators that strictly regulated AAP/PLAN activities enable from the sorts of marginal activities engaged in by the so-called special interest groups.

I can make this statement with certainty for several reasons. First, The Federal Elections Commission Act of 1974 which regulates campaign contributions, is perfectly straightforward regarding the manner in which PACs, such as AAP/PLAN, must operate. There is no ambiguity whatsoever about the fact that a Federal PAC may contribute no more than $5,000 to a candidate in any given election cycle. Yes, that is correct, $5,000 is the maximum amount a PAC can contribute to a candidate per election. In practical terms, this means that considering the average cost of a House election campaign (nearly $1 million) or a Senate campaign ($3 million), any candidate who is corruptible for such a paltry sum of $5,000 would have to be felony dumb, even if corruption was an explicit goal of the donor.

Another area of concern in the federal campaign finance conundrum is the special interest influence exerted by “soft money” contributions. In essence, soft money was a loophole that developed in recent years to provide candidates, contributors and political parties a means to evade federal contribution limits.

Federal law prohibits corporations and labor unions from contributing any money to federal campaigns. Federal law also limits an individual to contributing no more than $2,000 to a federal candidate per election, and no more than $20,000 to a political party per year.

To evade these restrictions, soft money contributions have been given by individuals, corporations, unions or others directly to designated nonfederal accounts of the national political parties. The national party committees spend the money directly or through state parties on activities such as voter registration drives or get-out-the-vote drives that benefit candidates in federal elections. Through the 2002 election, soft money paid for so-called issue ads intended to influence the presidential election. Thus, the soft money contributions were laundered through the political parties in a way that allowed federally illegal money to nonetheless be used to influence federal elections.

Soft money excesses were the target of the Bipartisan Campaign Reform Act (BCRA) passed in 2002. Psychologists should be aware that AAP and AAP/PLAN have historically never been involved in making soft money contributions. AAP/PLAN’s contributions are always made directly to candidates’ campaign funds or their committees which are closely regulated by the Federal Election Commission (FEC). In fact, AAP expends a significant amount of time, energy, and financial resources complying with the many FEC filings required of a federally registered PAC. The last thing psychology needs is to be the subject of an FEC investigation. Not only would this reflect poorly on psychology, but it would hamper psychology’s relationship with the legislators we are attempting to educate about the importance of psychology. AAP pays meticulous attention to the FEC’s details.

Finally, psychologists should be aware that the excessively large political contributions permissible in states, like California mentioned above, are strictly forbidden in federal elections. Federal election law permits an individual to contribute a maximum of only $2,000 per candidate in an election. State laws are often far more permissive of large contribution amounts, by both individuals and organizations. California, for example, permits individuals to contribute over $20,000 to a candidate.

There is some good news for those who have serious concerns about the runaway train of campaign finance. The Supreme Court handed down a decision on December 10, 2003. It upheld most of BCRA campaign finance law and essentially killed any final hopes politicians and their parties had about returning to the days when unlimited contributions flowed freely into their hands via the soft money route.

The recent Court decision affirmed the core provisions of the BCRA, the largest overhaul of the campaign finance system in the last 30 years, locking in place rules that have been in effect since November ‘02. It upheld the ban on soft money and it restricted political advertising around election time.

This does not mean that money will no longer play a vital role in elections. No, money is far too important to simply fade away. Practically speaking, those who have skillfully found ways to raise hard money contributions in large amounts will hold the largest sword in next year’s elections. At the top of the list is President Bush, who has established a vast network of business executives and other loyal Republicans and has amassed roughly $110 million so far this year, with a goal of nearly $200 million by next November. Among the Democratic candidates, Howard Dean has far surpassed his party’s rivals by building an Internet-based network of contributors who have so far given more than $25 million.

But, the BCRA will, no doubt, change the playing field for thousands of corporations, labor unions and wealthy ideologues who gave about $500 million in soft money to the national parties in last year’s races. Some believe, however, that major donors will now direct that money to third-party organizations, creating a new loophole to circumvent the BCRA.

One major opponent of campaign finance reform commenting about the Supreme Court’s recent decision said, “soft money is not gone, it has simply changed its address.” Money in whatever form (soft or hard), whether we like it or not, will continue to be the coin of the realm in the campaign process.

For psychology to be heard on Capitol Hill, we have no choice but to speak with our checkbooks. AAPers already know this. It is our job to better educate our unaware colleagues about this fact. You can help by recycling this edition of Advance to your office mate, or at the next professional meeting you attend. Or, send this copy of Advance to a colleague with a personal post-it note attached encouraging your friend to contribute to AAP/PLAN. It is now easier than ever to make a PLAN contribution by simply visiting AAP’s website at: www.aapnet.org and clicking on, “Give to AAP/PLAN.” Donations can be made easily on-line. Here’s hoping that 2004 will be a healthy and productive year for all of you and for psychology’s political advocacy program.

Winter 2004 Newsletter