AAP Newsletters

While in Toronto, I participated in a symposium entitled, “The Implosion of the Health Care System — Implications for Psychologists”, which focused on the impending American health care crisis. Three of the five panelists provided reasoned and compelling arguments for radical change in the way health care is delivered and paid for in this country. I was the last presenter to speak at the symposium. It was my job to speak to the role played by politics in the health care reform equation. I delivered a rather gloomy report, I must admit. Just when the party was really starting to heat up, I came along and pulled the plug on the band. Sometimes reality does bite.

I am writing this on Labor Day, as political leaders make their rounds and shake hands with voters. Their speeches drift from celebrating workers to weighing in on the recall circus in California. Few, if any, will address the most pressing issue affecting working families today: affordable health care. A vast majority of the uninsured are workers and their families. Insured workers aren’t doing much better with double and triple-digit increases in their monthly premiums, skyrocketing deductibles and greater out-of-pocket charges at the doctor.

Isn’t it time for the most advanced nation in the history of the world to provide affordable care for every one of its citizens? Don’t be too quick to suggest that there is unanimity of response to this question. The answer, in fact, depends almost entirely on the particular ideology to which you subscribe.

Despite substantial evidence suggesting that nationalizing health care might very well make the most sense for Americans, political forces weigh heavily against such a system currently. The United States is unlikely to embrace universal health insurance for this country soon, if ever. Why is this so? Because, among many reasons, neither moral sentiments among a majority, nor political pressure from the uninsured, nor pure economic self-interest of those who would have to pay added taxes for it, furnishes the requisite political force to induce a majority of the nation’s political leaders to embrace that idea. Admittedly, this is a pessimistic conclusion, but looking at the past four decades of U.S. health policy makes that conjecture a good wager.

Since the passage of Medicare in 1965 (which was a substantial change, but restricted to only Medicare and as such affected only a part of the wider health system), every attempt to inject major health care system alterations has failed. All of us remember President Clinton’s debacle only ten years ago. Five years prior to that, the Medicare Catastrophic Coverage Act (a substantive medicare reform measure) was actually passed, only to be repealed a few short months later due to the huge public outcry from elderly beneficiaries who were furious after they started to look at the details of the bill.

You probably know that Congress is currently supposedly well on the way to passing an historic Medicare law that will, at long last, overhaul the huge government health insurance program and offer new drug benefits to 40 million elderly and disabled Americans. Lawmakers began meeting during the August Congressional recess to begin hammering out the differences between the bills already passed by the House and the Senate. It would seem that all they have to do is split the difference in time-honored legislative style.

Right?

Maybe, but here is the pessimistic view: That the differences at stake here are not the ordinary stuff of legislative compromise. That the conservatives in the House and the liberals in the Senate have profoundly different visions of Medicare, of social welfare programs and of government in general. And that those divisions will be hard to finesse, despite the efforts of centrists and pragmatists, like recent AAP honoree Senator John Breaux, in both parties, and the urgings of a White House intent on resolving the drug issue before next year’s election.

Can you simply split the difference when the two ideological camps are so profoundly at odds on the efficacy of government itself? One side sees middle class entitlements, like Social Security and Medicare, as enduring achievements of government at its best; the other as promises that cannot be kept unless the programs are modernized, reinvented to allow more competition and private market involvement.

Similarly, liberals increasingly see tax cuts as a calculated attempt to starve the government, and by extension, relentlessly trim its services; conservatives see tax cuts as empowering, taking money from a bloated bureaucracy and returning it to the taxpayers.

Medicare, and by extension, any move to nationalize healthcare is the battleground for this much broader struggle.

Conservatives argue that the program is a relic of the Great Society, a collection of government bureaucrats rigidly administering prices for an oncologist in Des Moines and a hospital in Houston. Moreover, many conservatives maintain, the program is not affordable, given the huge wave of 76 million baby boom retirees just over the horizon, and the ever growing costs of medical care and new technology.

Conservatives say that competition and private market forces will, eventually, do a better job of containing costs and serving beneficiaries than a centralized government bureaucracy ever could. If they lose this, conservatives argue, the traditional vision of a government-run social insurance program will not only endure, but prevail. Some say, Congress may never get another chance to “reform” Medicare because the closer the powerful baby boomer voting bloc gets to retirement, the harder it will be to do anything that seems to restrict its benefits.

In short, this is the proverbial fork in the road of history. This is not something where you can just say, “Let’s strike a deal.”

Liberals, on the other hand, see Medicare as an extraordinarily successful government program that lifted the elderly out of the charity wards and into the mainstream of American medicine, a middle-class entitlement that reminded Americans of the good that government could do. From its start in 1965, Medicare has performed a role that government is uniquely suited to, liberals argue — spreading the risks and the benefits, protecting a vulnerable population.

Even so, leading Democrats in the Senate, including liberal patriarch Ted Kennedy, say they are willing to accept modest structural reforms, and yet another experiment with private health plans in Medicare, in exchange for finally adding drug benefits. After all, they are acutely aware that Republicans control the House, the Senate and the White House, and that prospects for Democrats’ recapturing any of the three next year are — to put it kindly — hardly a sure thing. Another chance at $400 billion for drug benefits may not come along soon.

So leading Democrats signed on to a bipartisan compromise bill in the Senate, where the Republicans have a tiny majority but rules give the Democratic minority much more influence than they have in the House. But the party’s liberals have drawn the line at the House bill; its competitive provisions are unacceptable to them.

The pragmatists argue that there is a “third way” on Medicare; a “down payment” on drugs for the left, a demonstration project on competitive health plans for the right. In fact, that may be the compromise that emerges, producing a law signed by a cheerful President Bush before a happy bipartisan audience.

But there is another view in both camps: That there are no win-win solutions here. That if Medicare legislation is finally passed, one world view will have won, the other lost. That you cannot split the difference when the two parties are so profoundly at odds on government itself. If history is any indication of the future, that may well be the fate of the current Medicare reform attempt.

Although the political deck seems powerfully stacked against universal health insurance or any radical reform to the system in the United States, every so often the stars do align, to make breakthroughs in public policy possible. It was so with the original enactment of Medicare in 1965, with the enactment of the seemingly doomed 1986 general income tax reform legislation, and with SCHIP in 1997. As champions of health care reform, psychology will continue to press our legislative agenda with our friends on Capitol Hill as well as attempt to broaden relationships with those legislators who may not yet fully support mental health initiatives. It is the health policy analogue of permanent military preparedness.

Fall 2003 Newsletter

The Italian proverb, “Uno sciocco e il suo denaro son presto separate” has no relevance to the psychology community. Roughly translated, it means, “a fool and his money are soon parted”. By now, it is common knowledge that psychologists do not part easily or quickly with their money, at least in the context of supporting psychology’s political advocacy programs (present company excluded). Are psychologists smart? Of course they are. Does it follow logically that one can not be a fool and at the same time ignore the tremendous influence of politics in our professional lives and those of our patients? Hmmmm. Could it be that we are too smart?

Plato, no slouch in the thinking department, also commented on being smart when he said, “Those who are too smart to engage in politics are punished by being governed by those who are dumber”. It is up to those of us who are not too smart to appreciate the importance of engaging in politics to get this message out to our “too smart” colleagues, one colleague at a time. (See the new “Friends of AAP” item in this edition of Advance)

Much has been discussed previously in Advance and elsewhere about psychology’s relatively poor performance in political giving. Our colleagues are often shocked to learn about the tiny percentage of psychologists who contribute to AAP in support of political action (5% of practitioners). More seem surprised to hear how little it would take for psychology to become a major league player in the political action game (less than $50/year from all practitioners). Equally unclear is what the benefit will be of reaching the goal of elevating psychology’s political giving profile by 200 or 300 percent. How will such an increase actually affect psychology’s legislative agenda?

I think it helpful in addressing the above question to first look at the experience of other groups and how they operate in the face of a highly publicized issue that is currently on the front burner in Washington. Three of the most powerful national special interest groups are preparing for battle over the medical malpractice issue: trial lawyers, insurance companies, and the American Medical Association.

The campaign to cap medical malpractice awards got a boost in President Bush’s State of the Union address in January. The president had been lukewarm on the issue—up until Senator John Edwards (D-N.C.), a former trial lawyer, announced he was running for president. After that, medical malpractice reform became one of Bush’s top priorities. The president argues that high monetary awards drive up the cost of malpractice insurance and put doctors out of business. A bill by Rep James Greenwood (R-Pa.) would cap damages for pain and suffering at $250,000, and limit the amount of time a plaintiff has to file a lawsuit. Greenwood’s bill is identical to one that the House passed last year. Democrats oppose the bill, saying that insurance companies—not trial lawyers—are the ones to blame for high premiums.

The issue promises to pit doctors and insurance companies against one of Capitol Hill’s most generous campaign contributors: the Association of Trial Lawyers of America (ATLA). ATLA runs one of the top PACs in the country and contributed $3.7 million in individual, PAC and soft money donations during the 2002 election cycle. But ATLA will have to marshal all its power to compete against the lobbying campaign launched by the American Medical Association last year. The AMA is one of the top donors in the country, contributing nearly $20 million in individual, PAC and soft money donations since 1989. During the 2002 election cycle, the AMA contributed $2.7 million. The group is trying to raise $15 million for a nationwide media campaign to promote liability reform. Stay tuned as this drama unfolds over the next few months to witness hardball lobbying at its fiercest. Does every member of Congress have extensive knowledge about the legislative agendas of the American Medical Association, the insurance industry, and the ATLA? You bet they do. Members of Congress encounter AMA lobbyists daily at countless fundraising venues. Everyone knows that the AMA is a powerful force to be reckoned with on all legislative matters in health care and beyond. Because the AMA contributes nearly $3 million per election cycle to political campaigns, they are instantly members of the inner circle, major stakeholders with the highest level of recognition. While contributions totaling $2.7 million do not in any way cause favorable votes among members of Congress, it does make the issues that are of concern to that group rise to the extent of being front and center in a majority of legislators’ minds. They may or may not agree with the position of the AMA, but it is a certainty that they are not only very clear about what ISSUE the AMA is advocating for, but also what the AMA POSITION is on any particular matter of concern to the AMA and its constituents.

Currently, psychology has developed many good friends in both the House of Representatives and in the Senate. A smaller number of those have been our champions on a number of issues. Of course, the three psychologists who serve in the House of Representatives are tremendously valuable: Congressmen Strickland, Baird and Murphy. In addition, names like Wellstone, Domenici, Norwood, Thurman, Kennedy, Inouye, Breaux, Jeffords, Harkin, Stark, Cunningham, and others have been enormously supportive of psychology’s efforts over the course of many years.

Psychology’s contributions to the reelection campaigns of these folks are vital to sustaining and advancing our legislative agenda. As effective as these legislators have been in helping us, we need to do more to develop working relationships with greater numbers of members of Congress (MoC). With 435 members of the House and 100 members of the Senate, the demands for AAP’s limited resources are very high. Currently, AAP contributes to only 20% of these members’ election campaigns. When AAP provides the funds for an APA Practice Organization lobbyist to attend a campaign fundraising event in Washington, it affords our lobbyists invaluable opportunities to establish “face time” with a MoC and his key legislative staffers. These contacts often translate to much closer working relationships than can be developed by routine visits to a Congressional office which occur during the overwhelmingly hectic day of a MoC. With such a dizzying array of meetings scheduled during every minute of the day, it’s a wonder that the typical MoC can remember even his own name by the end of each day. Attendance at the more informal fundraising events allows our lobbyists access and an opportunity to evolve from being simply a blip on the radar screen of a MoC, to then interacting on a first name basis and, hopefully, in time, being relied upon to provide the MoC information about all pending legislation concerning mental health.

Sure, it would be nice if forming these relationships did not have to take place in the context of fundraising. But, the reality is that fundraising is a top priority for all elected officials, consuming a very substantial amount of their time and activities. Newly elected Congressman, Dr. Tim Murphy complained to me recently about the burdens of fundraising. He would much prefer spending all of his time developing public policy than be forced to devote so much time and energy to reelection efforts. Fundraising activities consume nearly half of the time of a member of Congress, especially newly elected members who their opposition view as more vulnerable to elective challenges.

Psychology’s current resources are allocated very judiciously, given the limited amount with which we have to work.

Imagine how much more successful we could be if, instead of contributing to only 20% of the federal election campaigns as we now do, we could contribute to 75% of those campaigns. Further imagine, if instead of contributing an average of $1,000 to each campaign, we could contribute the maximum allowable ($5,000/election) to these same election campaigns. This elevated level of giving would allow psychology to be more helpful to those MoC whose ideology is consistent with psychology’s and would better help to sustain and nurture those relationships.

In addition, it would allow us to reach out to potential new friends in Congress by giving us access to them in a variety of settings (campaign events in their home districts, Washington dinners, etc.) where local psychologists and APAPO lobbyists could inform them of our issues and agenda and work toward gaining their support. Currently, this broad range of access is not available to us and, consequently, a majority of the 535 MoC are not knowledgeable about psychology’s issues. Sadly, many are not even aware of them. This is a major deficiency that can only be corrected by becoming major players in the political giving game.

I know I can get carried away with this theme, but indulge me for just a moment more. Imagine, further, that with additional resources available to psychology, we could actually begin to have some influence in shaping a legislature that would be more in tune with psychology’s legislative agenda. Currently, the overwhelming majority of our contributions must go to a relatively small cadre of incumbents (approximately 150) because incumbents are reelected over 95% of the time. With AAP’s limited resources it would be foolish to invest in candidates that have to overcome tremendous odds to win an election against a well funded incumbent. But, with substantially greater resources to invest, psychology could support more campaigns of candidates who are clearly sympathetic to psychology’s concerns despite their non-incumbent status. Certainly in open election races where there is no incumbent (due to retirement, running for higher office, etc.), this strategy would be eminently feasible. Actually this strategy is employed by AAP now, but only a very small scale basis.

In closing, while I don’t fully agree with George Bernard Shaw’s quip, “Lack of money is the root of all evil”, psychologists would do well to join the real world of politics with their checkbooks in hand. It’s interesting that psychologists are quite supportive of the APA’s Public Education Campaign (PEC), aimed at informing the general public about what psychology has to offer. The PEC costs roughly $1 million per year (a bit less since the budget reductions of the last year). What I am proposing might be called the Congressional Education Campaign. $1 million per year would go a long way toward educating 535 members of Congress about the value of psychology. The benefits to psychology of having all members of Congress aware of what we have to offer would be, as the advertisement states, priceless.

Psychologists often say they are not interested in politics. Make no mistake about it, in the modern world, in which thousands of people are literally dying every hour as a consequence of POLITICS, no issue or policy anywhere can begin to be credible unless it is informed by political awareness and principles. Groups who recognize the critical importance of neither, produce utopian drivel destined for the eternal trash heap. To a large extent, this is what doomed the major overhaul of the American healthcare system in the early 90s known as the Clinton National Health Security Act. In large part, President Clinton undervalued the role of politics in promoting his health care reform proposal.

Do yourself and psychology a favor. Take the AAP application in this newsletter and use it to recruit a friend to join AAP. While lack of money may not be the root of all evil, psychology’s future would be much brighter if we had a bigger chunk of money with which to educate Congress and promote our legislative issues.

Summer 2003 Newsletter

There is no shortage of explanations about why psychologists do not, as a rule, make political contributions. You have probably heard them all in one form or another: “I pay so much in dues to both APA and my State Association that I’m broke”; “APA special assessment fees take care of all that”; “I think the political system is rotten and I won’t support any politician”; “psychologists ought to be able to rely on our research data to persuade legislators of the merits of our case, not the corrupt system of politics”; “politics doesn’t have any effect on me or my patients”; “federal legislation is of no relevance to the particular kind of practice I have”, and on and on. As you all know, none of these rationalizations can withstand the test of even superficial scrutiny.

Rather than argue about the type of resistance represented by each of the above rationalizations, I’d like to briefly examine: 1) What the factors are that actually motivate people to contribute to political campaigns, and 2) Prochaska’s change model with reference to political giving. Each AAP member is on the front line in our battle to enlist the support of our uninvolved colleagues. I know you are all over-committed as it is, but we need for you to add one more task to your professional role. We need you to become an emissary in the mission to convert our uninvolved colleagues. They have unfairly placed all the burden for advancing psychology’s public policy agenda on your shoulders and a relative handful of others’ for too long.

By definition, as members of AAP, all of you are far more evolved in your understanding and appreciation of how money affects the political process than are our uninvolved and certainly uncommitted colleagues. They have yet to acknowledge that politics is integrally intertwined with their professional lives as psychologists. Ron Fox, AAP Chair, has devoted all of his recent newsletter columns to a “call to arms” for the profession. He spells out what we need to do to advance psychology’s legislative agenda. We need participation from all of the 40,000+ psychologists who pay the APA special assessment fee, not just the small fraction of us who now participate.

As emissaries, you will need to know among other tribute to campaigns. This is one habit that seems almost nonexistent in their repertoire of behaviors. It makes eminent good sense for us to try to further develop this habit among our colleagues.

Remember though, the second most powerful reason for giving is attributable to personal relationships. Your colleagues will give if you ask them to as a personal favor to you. Over time they will develop this as a habit.

With apologies to my psychoanalytic friends, Prochaska’s transtheoretical model of change may be useful for looking at our uninvolved colleagues if we are to persuade large numbers of psychologists to join us in the battle by developing better political giving habits. You may recall that Prochaska proposed five stages in the change process: Precontemplation, Contemplation, Preparation, Action, and Maintenance.

Some psychologists are Precontemplative and have never even heard of the term “political giving” or think that it doesn’t apply to them. This group is relatively large despite all the information that has been disseminated over the years about AAP and its importance. Some are Contemplative and interested in learning more about how political advocacy can affect psychology. Other folks are stuck in the Preparation stage and are making plans, “yeah the next time I get an AAP solicitation in the mail, I’ll send in a completed application along with a check or make a contribution to PLAN. Some people are in the Action phase and actually do pay dues or make contributions, sometimes. And other people have arrived at the Maintenance phase and, like you, always support the cause. They have developed a most positive habit.

From a practical standpoint this little idea of stages of change has big implications. A large number of psychologists know nothing about political giving while a small minority of us are integrally involved. And then there are several flavors in between. These different stages define different kinds of people. And clearly we must use different persuasion tactics on people depending upon what stage they are in.

The practical implications for all emissaries trying to create what has heretofore been an elusive “culture of giving” among our brethren are many. For starters, we’ve got to tailor our argument to the stage of change that our recalcitrant colleague happens to be in: ignorance, learning, planning, doing, habit.

We can’t approach somebody in Stage One (ignorance) the same way we’d approach somebody in Stage Three (planning). Thus, you should determine where your target receiver stands in the Stages. The goal is to move to the next stage.

To be sure, I am often impatient with the process of change. Intellectually, however, I know I can’t expect to move people from Stage One (ignorance) to Stage Five (habit) in one fell swoop. The smart play is to influence your target through all stages one at a time. Thus, you are building bridges across stages (a nice image there) because you can’t skip stages. While the ultimate goal is to stimulate the formation of habitual giving among all our colleagues in order to advance psychology’s legislative agenda, it will take time to reach that goal.

If each of you could influence just one or two colleagues this month, we could triple psychology’s influence on Capitol Hill. Read the highlights of Dr. Larry Sabato’s State Leadership Conference speech (on page one) to amplify how important this goal is. You can obtain AAP applications and information about AAP including the past and current editions or this newsletter online at AAP’s website: www.aapnet.org. You can call 800.869.6595 and we will send you applications and other materials to help you convert the uninvolved. We are grateful for all you do.

Spring 2003 Newsletter

The U.S. mental health system “is in disarray” and is not “oriented to the single most important goal of the people it serves — the hope of recovery,” according to a November interim report by the President’s New Freedom Commission on Mental Health. AAP member Deanna Yates is one of 15 panelists serving on the Commission appointed by President Bush and tasked with making recommendations about how to improve mental health care nationwide (Dr. Yates gives a brief update of her assignment elsewhere in this edition of Advance).

The Commission’s report, much of which is well known to psychologists, states that 5% to 7% of adults and 5% to 9% of children in the United States have a “serious mental illness” or emotional disturbance that affects functioning at work, school, home or in social situation. Quality of life can be “tremendously improved” when a mental illness is diagnosed early and appropriately, the report says, but it notes that the varying missions, settings and financing of private and public mental health programs act as barriers to care.

The Commission says that the mental health system is a “maze instead of a coordinated system” and “navigating this maze” is left to people with mental illnesses and their families, who are “least-equipped to deal with the complexities of the system.” According to the commission, 50% of people who need mental health treatment do not receive it because of barriers to care. Commission Chair, Michael Hogan said, “The so-called mental health system is fragmented and in such disarray that frequently it can’t get the services to the people who need them.

The report also identifies several barriers that “needlessly impede” access to care: fragmentation and gaps in care for children and adults; high unemployment and disability among the mentally ill; “insufficient attention” to older adults; and inadequate national attention to mental illness and suicide. The commission, which identifies a number of successful community based mental health programs, says that many individuals could recover “from even the most serious mental illnesses” if they had access to state-ofthe- art treatments “tailored to their needs,” support systems and community assistance.

Clearly, much of the information contained in the report is old hat for psychologists who have been involved in the health care reform debate for the past 10 years. But, the fact that the Commission was established by a Presidential Executive Order should give it weight that heretofore has been missing. This alone makes the Commission and the recommendations from it very promising to us as psychologists. It should serve to greatly strengthen the Surgeon General’s report published 3 years ago which for the first time formally acknowledged that mental health is a legitimate part of overall health and that efficacious treatments for mental disorders exist and should be deployed. Unfortunately, the Surgeon General’s Report received little attention in the halls of Congress and proved to be of little appreciable value in mental health public policy reform. A Presidential Commission’s recommendations have far greater potential to tangibly impact the system.

Psychologists know the inadequacies of the current system backwards and forwards. We have been the ones delivering mental health services to those in need at the same time that the managed care industry has been obliterating the quality and provision of those very services. What then can we expect when the final report from the Commission inevitably demonstrates: that the need for these services is great, that effective treatments for mental disorders are available, and that the cost of providing these services is reasonable?

There is proverbial good news and bad news with regard to the above question. The good news is that the system as we know it can’t survive much longer. The bad news is that the economy is in such a steep decline that government financing, necessary in most plans for change to occur, will be even more difficult to secure than is usually the case.

Readers of this column are well aware that a consensus is building which suggests a major meltdown is imminent in health care delivery based on: 1) A Recession, No jobs, Average premiums at $4,000 a year and reduced benefits with COBRA benefits basically unaffordable; 2) Health care cost escalation for employers and greater cost sharing is passed along to individuals who can barely afford the $2,600 to $7,000 premiums; and 3) Disappearance of government surpluses along with large deficits in state Medicaid programs.

In a strange way this is good news for those of us who believe the current system is a sinking ship that can’t be salvaged to meet the health needs of the richest country in the history of the world. In the last edition of Advance, new data from the Harris Poll were cited which indicate that favorable sentiment about health reform is now held by the majority of stakeholders in health care.

Adding more urgency to this sentiment are recently released data indicating that now only 58% of patient care physicians in California are accepting new patients if the patient has HMO insurance coverage. The percentage of specialists with HMO patients fell from 77% to 62% between 1998 and 2001. The rate of physician participation in private HMO plans is approaching the historically low rate of physician participation in Medi-Cal, the state’s insurance plan for low income Californians. A privately insured HMO patient in California now faces almost as much difficulty as a Medi-Cal patient in obtaining a new patient appointment with a new doctor. The problem of lack of availability of physicians in many regions of the state is largely due to physicians not accepting patients with certain types of health insurance (or without health insurance altogether) rather than due to an absolute shortage of physicians practicing in California.

Because of the ever worsening health care environment, it is very likely that politicians will once again be more motivated to address the issue. In fact, we are already beginning to see Democrats publicly seizing the issue of health care to regain political traction after the losses they experienced in the midterm elections. Sen. Edward Kennedy (D-MA) recently said that he will push for universal health care, a Medicare prescription drug benefit and increased Medicare reimbursements for providers when Congress convenes next year. Former Vice President Al Gore recently endorsed a single-payer health care system. Gore said that he has “reluctantly come to the conclusion” that a single-payer health care system would serve as the most effective proposal to provide universal health coverage in the United States. Likely Presidential candidate Senator John Kerry (DMA) has announced that he will be announcing a health reform measure shortly. Senator John Breaux (D-LA) has a Medicare reform plan, and Governor Howard Dean (D) of Vermont will be discussing his plan during his presidential campaigning in the months ahead.

All this activity induces hope. However, we need to remember that our national focus is squarely on the impending war with Iraq and the huge issue of national security, followed closely by concerns about the grim economic picture. Americans have not had the “conversation” about whether health care is a basic right. Once American consumers who are covered by insurance begin to experience the “sticker shock” of real health care costs and larger financial burdens of co-pays and coinsurance, the conversation will begin in earnest. As the Harris data point out, there is already support for fundamental health reform, just not yet on Capitol Hill.

Change in health care can only occur, in my view, if the American voting public begins to feel the pain that is now only felt by the 40 million uninsured and the 20% of the rest of us who have health insurance and actually require some form of health care (80% of us don’t attempt to access care and therefore have no awareness of problems with the system in any given year).

The following point should be underscored: just as cost is a driver for reform, it is also a barrier. Ponder how the Medicare prescription drug benefit has been stalled in Congress. The usual argument against it is that we simply cannot afford it. The U.S. didn’t accomplish national health reform during a budget surplus situation when the country and most Americans felt more financially flush.

As employers increasingly shift insurance costs to employees due to the runaway expenses of our current inefficient system, the American public will voice their distress based on genuinely felt needs. Reform opponents will then no longer be able to use the fallacious argument that only greedy doctors favor reforms so they can fatten their wallets. Voters will have to feel major pain before any significant change in the health delivery system can occur. But remember what is at stake in changing the existing structure of health delivery. Health care represents a one and a half trillion dollar industry (nearly 15% of our Gross Domestic Product) with a huge number of special interest groups highly vested in preventing changes that would be for the greater good.

Psychologists represent one relatively small interest group in the health delivery arena. With a report from the President’s Mental Health Commission which will likely encourage increased access to mental health services, Psychology’s lobbying team will have an even greater burden to shoulder. We will continue to struggle both to maintain our inclusion in the larger health care firmament, and to insure that we will be players in the changing mental health delivery infrastructure that hopefully will be created. Not only will our usual opponents increase their firepower to defend the status quo, but there will be budget deficits at the state and federal level as well, making increased services harder to sell to lawmakers. The good news is that the public will be demanding change and this is what will ultimately force legislators to end the gridlock and the tinkering with incremental changes that has failed to fix the system.

All of us must be involved in this effort by supporting the work of our Washington advocacy team. The potential for positive change is great. The responsibility for insuring that change in the system will incorporate a high quality mental health component must be shared by all of us. I know I am speaking to the choir, but please be prepared to give some of your time and resources to this effort. Read AAP Chair Ron Fox’s column in this edition. Help us to recruit more of our colleagues to pitch in and help balance the load more equitably. Use the new member application form in this issue of Advance to recruit as many new members as you can for this effort.

Winter 2003 Newsletter

What happened to the national fervor for health care reform that nearly came to fruition during the first half of 2001? A key element of that reform, the Patients’ Bill of Rights, has all but disappeared as it remains frozen by Congressional inactivity. Are we psychologists the only ones feeling like the sky is falling on our nation’s health care system? The answer is clearly, no. However, like so many other issues that had traction and loomed large in the public policy arena prior to 9-11, health care reform has been moved off the legislative radar screen, a victim of the heightened national security concerns which understandably became America’s number one priority.

Now though, fully one year later, there again appears to be growing concern about health care in this country. According to a Harris Poll released in early September, the United States has a “considerable appetite” for health care reform, and a “stronger consensus for radical reform is building” among the public, employers, providers and others in the health care industry. Psychologists, of course, have held these beliefs for almost a decade now.

In the survey, Harris researchers interviewed separate samples of 1,013 adults, 406 physicians, 305 employers, 101 health plan managers and 301 hospital managers to determine “what they thought of the nation’s health care system.” According to the survey, 56% of the public, 46% of physicians, 48% of employers, 50% of health plan managers and 51% of hospital managers said that the health care system requires “radical change.” Although public opinion has fluctuated on the issue over the past 20 years, 56% of the public said that they favor “radical change” of the health care system. The survey predicted that dissatisfaction with the health care system would increase over the next few years as a result of increased out-of-pocket costs, concerns about prescription drug prices and a possible increase in the number of uninsured Americans.

The survey also found:
• The percentage of doctors who endorsed radical change reached a low of 32% in 1994 but has increased over the past eight years, perhaps as a result of anger about managed care. • In 1999, health plan managers had remarkably positive attitudes about the health care system, but the percentage who favor radical change has increased over the past three years, from 31% in 1999 to 50% in 2002. • Although employer attitudes about the health care system have shifted very little, 48% favor radical change today, the highest percentage between 1993 and 2002.

The survey concluded that a majority of those interviewed did not have a good opinion of the health care system as it is now. In addition, the survey predicted a big push for reform as employers and health plan managers have become more hostile toward the system in 2002 than in past.

Despite these poll results, it is not likely that we will be popping any champagne corks this Fall over health care reform. Congress has had a full plate of health care issues with which they have struggled since the beginning of the year including among others, Medicare reform, patients’ rights and the growing numbers of uninsured. It is highly unlikely that anything of substance will emerge in any of these areas during the shortened session of Congress now underway prior to the Fall elections. Needless to say, our own mental health parity legislation may experience a similar fate in the short term, despite the public statements made by President Bush last Spring about the importance of passing such a measure. Even though an august newspaper, the Washington Post, published an editorial on September 9th, reversing its former position on mental health parity and now urging its passage, hope remains dim for Fall legislation. The likelihood of passing related health reform measures is also tenuous, at best.

To illustrate how problematic health care issues are in Congress, the Senate in July rejected four competing Medicare drug benefit bills. The House passed a Republican-sponsored bill that included a Medicare drug benefit in June. Efforts to negotiate a compromise in the Senate are hampered by how to reconcile Senator Grassley’s (R-IA) determination to have private health plans run a drug benefit with Senator Kennedy’s (D-MA) goal of offering uniform Medicare coverage to all seniors. On another front, physicians and other Medicare providers are turning up the pressure for a bill that would reverse Medicare reimbursement cuts scheduled to take effect this fall. Under changes mandated by the 1997 Balanced Budget Amendment, home health agencies face a 15% cut in their Medicare payments on October 15. In addition to these, generic drugs, medical malpractice, and the perennial issue of the uninsured continue to be hot topics of debate and a fair amount of rhetoric inside the beltway.

The bad news is that legislators in Washington are still deeply scarred by the 1994 debate and defeat of the Clinton health care reform proposal which has rendered them nearly incapable of tackling the big picture of health care reform. The good news is that only very small minorities of any of the five groups surveyed in the Harris research (the public, physicians, employers, health plan managers, and hospital managers) hold a good opinion of the health care system as it is now. Those who believe that “on the whole the health care system works pretty well and only minor changes are necessary” include only 19% of physicians and smaller percentages of all other groups surveyed.

The survey provides other indicators that the public’s sentiment for change of America’s deteriorating health care system is moving in the right direction. Chief among the reasons why we may expect to see a big push for health care reform on the horizon after the elections is the finding that employers are more hostile toward the system now than they were in any of the Harris Polls’ previous surveys. So too are health plan managers.

The public also appears to have a considerable appetite for health care reform, even if the radical change score is lower than it was in some previous years, particularly in the early 1990s. But only 17% of the public thinks that the system works pretty well and only minor changes are necessary. Almost twice as many (31%) think that we need to completely rebuild the system, with almost everyone else (49%) thinking that fundamental changes are needed.

I am betting that the 108th Congress, regardless of which party ends up in control of either house and despite the political danger surrounding health care reform, will have no choice but to begin substantial reform of the system. Let’s make sure that Psychology will be at the table to participate in the decision making process. Talk to your friends and colleagues and make sure they join you in supporting AAP.

Fall 2002 Newsletter

I have a confession to make. I’ve begun to identify with one of Hollywood’s most memorable, yet clearly deranged characters. It’s true, I think I am beginning to morph into Howard Beale, “the mad prophet of the airwaves,” who dominates our memories of Paddy Chayefsky’s screenplay, “Network.” You surely remember Beale in his soaking-wet raincoat, hair plastered to his forehead, shouting, “I’m mad as hell and I’m not going to take this anymore.”

Well, I’m mad too, and I’m on the verge of opening my window and begin shouting. I’ve had it up to here with the obstructionism, the unprovoked attacks, the audacity, and the dishonesty that the American Psychiatric Association (Apa) has unrelentingly assailed psychology with for so long. You don’t have to be a psychologist to recognize that the tactics employed by the Apa are causing quite a stir among the public at large these days. The Boston Globe, Time Magazine, The Today Show and others have recently featured stories about the internecine battles being launched by psychiatry against psychology. There is a long and full history of these sorts of activities beginning more than a century ago.

Psychiatry would have you believe that the current attacks have been instigated solely by psychology’s wish to practice medicine by prescribing dangerous drugs without going to medical school, which has become the feeble, onenote defense tactic they use to try to dissuade law makers from granting appropriately trained psychologists the right to prescribe psychotropic medications.

To be sure, the passage of a prescribing law recently in New Mexico (see related story in Advance) has served as the proverbial straw to break the camel’s back. But, don’t believe for a minute that psychology’s pursuit of prescribing privileges is the root source of this conflict. Ray Fowler, the American Psychological Association’s (APA) CEO, recounts a brief summary of psychiatry’s long history of offenses in a paper he delivered to The African Regional Congress on Psychology in 1999. Ray introduces his paper by mentioning the rich history of the science of psychology dating back to the APA’s founding in 1892. He then zeroes in on the heart of the matter by discussing how different the development of the professional side of psychology, the applications of psychology to human problems, was. He notes that this side of psychology progressed more slowly and had to overcome substantially more resistance than the scientific side. He cited the resistance of the medical profession, and particularly of psychiatry, to the development of professional psychology as having been strong and consistent throughout the history of professional psychology in the United States. So, it is time for any of you who remain devoted to the misguided notion that psychology’s growth and achievement of stature in the mental health firmament was smooth and effortless, to revise your thinking. Know, for example, as Ray points out, in 1894, the medical society of the state of Massachusetts tried to pass laws to limit the practice of psychotherapy to physicians only. William James (a physician himself), and also president of APA at the time, prevented the law’s passage by appearing before the Massachusetts legislature and declaring that neither psychologists nor physicians knew much about psychotherapy, but the promise for future progress lay more in the province of psychology than in medicine.

Organized medicine’s attempts to halt the expansion of psychological practice has been unremitting from that point through today. Medical societies have used their much greater financial and political strength to block or at least to delay almost every expansion in the scope of practice of psychologists. Ray Fowler detailed some of the more egregious obstacles interposed by medicine from, the early days of psychological testing, when laws were passed requiring that even the determination of an IQ, based entirely on the results of testing by a psychologist, had to be confirmed by a physician. The use of psychological testimony in court was delayed for years by the efforts of medical groups to discount their significance. Psychiatrists tried for decades to prevent psychologists from diagnosing mental disorders, claiming that diagnosis was exclusively a medical function.

The resistance of organized medicine to the practice of psychology greatly intensified after World War II as increasing numbers of psychologists moved into the practice of psychotherapy. In many hospitals and clinics, psychologists were regarded as psychometricians and permitted to do psychotherapy only under the supervision of a psychiatrist. Psychoanalytic training institutes, largely dominated by psychiatrists, routinely excluded psychologists until that exclusion was challenged by psychologists in court in the 80’s.

Psychiatrists were particularly eager to prevent competition in the independent practice of psychotherapy. When psychologists initiated licensing laws to regulate the practice of psychology and protect the public, medical societies, and particularly psychiatrists, used their money and influence in an effort to defeat these laws. They eventually lost the battle—every state now has licensure—but they were successful in delaying licensure in some states by up to 20 years.

Efforts to obtain hospital privileges for psychologists in the early 80’s were severely hampered by psychiatry’s interference. In the late 80’s, when psychology was trying to rectify an error excluding psychologists from the Medicare benefits program 20 years earlier, psychiatry was again our major opponent in Congress. Only three years ago, the Dr. Laura debacle thrust a misinterpreted APA Journal article dealing with sexual abuse onto the national stage and proceeded to spin out of control resulting in a Congressional Resolution to condemn the APA. Rather than step up to the plate and support the principle of academic freedom as any respectable profession should have done, the Apa took the low road by going out of its way to write a letter to Congress criticizing the APA, underscoring that psychiatry had no role in the matter.

If you still think that organized psychiatry is simply an avuncular group whose goals are in synchrony with psychology’s, I submit to you the following excerpt from a December issue of the Psychiatric News . . . Assembly Speaker Nada Stotland, M.D., led the Assembly in recommending that Apa adopt a position statement on the following . . . . the position paper will be forwarded to the Board for consideration at its December meeting: Access to Comprehensive Psychiatric Assessment and Integrated Treatment: When patients are referred for treatment for an apparently serious mental disorder, many managed care organizations initially refer them to a nonmedical mental health practitioner, and referral to a psychiatric physician for medication management may occur only later. The justification for this “split treatment” protocol includes presumed savings, yet these shortterm savings can be more than offset by serious long-term consequences for the patient. Thus, “Apa strongly supports a protocol by which any patient who is referred for mental health care should receive a comprehensive psychiatric assessment within a clinically appropriate time, [and] treatment planning should be undertaken only after an accurate diagnosis has been formulated by a psychiatrist, the clinician equipped with both medical training and a biopsychosocial perspective.”

The above simply represents one of the most recent attempts by psychiatry to medicalize psychotherapy. As they become more desperate, we will undoubtedly see increasing attempts by psychiatry to erroneously proclaim the existence of an hegemony in mental health and assert that they are the only qualified gatekeepers for determining the allocation of mental health resources for all Americans.

It is regrettable, especially at this point in time as public policy debates about mental health are reaching a crescendo on Capitol Hill (mental health parity bill, the need for increased funding for MH research, etc.), that psychiatry persists in its misguided and unsuccessful strategy of attacking psychology and meddling in matters which have no bearing whatsoever on their profession. Friends of mine in the California State Legislature used to refer disparagingly to the conflict as the PP Wars. When the mental health field can least afford it, at a minimum these attacks by psychiatry prove to be terribly distracting to the memberships of both groups and the organizations representing them. They drain the organizational resources which could be put to far better use in promoting increased recognition and treatment of mental disorders, for instance. It is shameful, but true that significant organizational resources must be expended annually for the sole purpose of defending against attacks from psychiatry in the Legislature.

Of even greater importance, the attacks also cast the whole mental health arena as a kind of two ring circus, in the eyes of the media and of public policy makers as well. The bottom line is that psychiatry’s assault behaviors are more than simply destructive to psychologists, they jeopardize the creation of sound mental health public policy which would ultimately benefit the patients who most need our care. What a waste. I think psychologists may unwittingly contribute to this unflattering appraisal to a certain extent. When faced with conflict, psychologists often choose the course of least resistance, burying their heads in the sand. As individuals, we are wont to say that these inter-professional battles are not our concern primarily because as individuals, at the local level, we get along so well with our psychiatry cousins. While this is true, we should be very clear about the fact that at the organizational level, the Apa has not only never missed a chance to stick it to us, but they have gone out of their way to create opportunities to officiously involve themselves in psychology’s affairs.

Psychology at the national level has always adhered to a reasonable and just policy concerning other related professions. The APA has maintained the principle that every professional’s scope of practice should be determined by the legislatures governing those practices. It mystifies me that organized psychiatry has the audacity to actually believe they should determine another profession’s scope of practice. We must continue to work toward the goal of disabusing them of their notion that it is part of psychiatry’s province to govern psychology’s scope of practice. Do so by recognizing that our goals have best been achieved when we have pursued them without regard to psychiatry’s tactics of intimidation. Sadly, trying to accommodate psychiatry’s concerns by compromising our agenda has never been of benefit to psychology or to the patients who rely on us for services.

It is high time for psychology to take the gloves off and adopt the philosophy, ‘no more Mr.Nice Guy.’ We can no longer afford to sit by passively, feeling intimidated and accept the malevolence of the Apa. We should firmly reject their attempts to restrain our practice in areas where we are fully trained and oftentimes more competent than they are to provide mental health treatments. These matters should be determined only by our own competencies in practice areas and by legislators who write the laws, not by another profession’s transparent attempt to create a professional monopoly to protect their financial concerns. Only semi-facetiously, we could consider countering their baseless argument that, if psychologists want to prescribe psychotropics they should attend medical school, with, if psychiatrists want to provide psychotherapy they should be required to attend psychology graduate school training programs.

Most people remember, as mentioned above, that Howard Beale got fed up, couldn’t take it anymore and had a meltdown on the air. Don’t open your windows and starting shouting yet. Continue your collegial relationships with your local psychiatrist friends. It’s nice to dream about a day when psychiatry finally matures and successfully resolves the Eriksonian developmental stage of Integrity vs. Despair. If this resolution continues to elude them, I can only wish them what they deserve. In the meantime, don’t lose sight of the fact that organized psychiatry is no friend to psychology and is responsible for the waste of a good chunk of our limited capital spent in undoing the mischief that they propagate.

Summer 2002 Newsletter