Voices of reform.
Subject: Medical societies (Political activity)
Health care reform (Political aspects)
Mental health (Management)
Pub Date: 12/22/2009
Publication: Name: Annals of the American Psychotherapy Association Publisher: American Psychotherapy Association Audience: Academic; Professional Format: Magazine/Journal Subject: Psychology and mental health Copyright: COPYRIGHT 2009 American Psychotherapy Association ISSN: 1535-4075
Issue: Date: Winter, 2009 Source Volume: 12 Source Issue: 4
Topic: Event Code: 290 Public affairs; 200 Management dynamics Computer Subject: Company business management
Product: Product Code: 8622000 Medical Associations NAICS Code: 81392 Professional Organizations SIC Code: 8621 Professional organizations
Geographic: Geographic Scope: United States Geographic Code: 1USA United States
Accession Number: 216961281
Full Text: Members of the American Psychotherapy Association and other experts speak out about what a change to the nation's health care means to mental health.

The country is one step closer to some sort of nationalized health care reform, now that the House of Representatives passed the Affordable Health Care for America Act (H.R. 3962) on November 7, 2009. It passed by a very slim margin--a vote of 220-215. Like the voices in Congress, members of the American Psychotherapy Association have mixed views about what reform will mean for their practices.

"Who knows what the right one is?" said Ron Hixson, PhD, BCPC, MBA, LPC, LMFT, DAPA, and therapist in San Antonio. "The right wingers will see their golden goose cracking, and the left wingers are confused about which egg to pick, so it will probably come down to the lobbyists having the greatest impact on the written amendments or legislation selected to support."

"I'm not a fan of the current legislation that is moving through Congress," said Dr. Gary Brown of Los Angeles. "If passed in its present form, it will in the long run virtually eliminate fee-for-service. Reimbursement rates will go down to the Medicare level, and it will eliminate competition in the private sector. It will decimate private practice." "I believe that we do need health care reform, but I believe we need to do it incrementally," Dr. Brown continued. "I would start with tort reform, portability, tax-free savings accounts; tying premiums to lifestyle choices; covering young adults, and [applying] refundable tax credits for the uninsured. Implementing these ideas could certainly lower the overall health care costs we face as a nation, but none of this is being contemplated by the current majority in Congress."


Americans now predominately believe that tackling health care reform is more important than ever before--57%, up from 53% in August, according to a September poll conducted by the Kaiser Family Foundation. The proportion of Americans who think their families would be better off if health reform passes is up six percentage points (42% versus 36% in August), and the percentage that thinks the country would be better off is up eight points (to 53% from 45% in August) (Kaiser Family Foundation 2009).

"Without insurance coverage, more people with mental health problems would withdraw from the service due to stigma," said Linda Song, MD, PhD, and licensed clinical psychologist in Kensington, Maryland. "The coverage of [the] insurance company indicates that the mental health service is an official, scientifically-proven health service with the same concept as another medical service. We should increase the access to the mental health service at an early stage. Insurance should also increase the coverage of preventive services, such as family therapy/counseling parenting education, group therapy, and marital/premarital counseling/therapy, which, in a long-term run, should reduce the cost of the service of mental health."

A substantial majority of Americans continues to back individual reform components designed to expand coverage, including an individual mandate (68%), an employer mandate (67%), and an expansion of state programs such as Medicaid and the Children's Health Insurance Program (82%) (Kaiser Family Foundation 2009). "Health care reform has been an agenda item for recent presidents," said Noah Hart, Jr., EdD, DAPA. "There is no question about the need for it; what [the] reform will be is the issue. As the nation's population evolves, health care needs to evolve and migrate. Much of the recent debate, particularly town hall meetings, has been about cost. Who is going to pay for health care reform? Much of the current health care cost is not clearly identified. Specifically, a large percentage of the homeless, the working poor, the unemployed, and others who have no health care insurance use hospital emergency rooms. All taxpayers pay for their care.

"The need for health care reform is emphasized by the current H1N1 flu pandemic which underscores the potential impact of globalization, immigration, migration, and tourism on the U.S.'s population. Americans live in a world wherein illness and disease can be easily transmitted among global communities within hours. For this reason and others, health care reform which acknowledges and is responsive to contemporary global health issues is a national imperative."

The component that draws the strongest support across the political spectrum is the requirement that health insurance companies cover anyone who applies, even if they are sick or have a preexisting medical condition. Overall, eight to 10 people support the idea, including 67% of Republicans, 80% of independents, and 88% of Democrats (Kaiser Family Foundation 2009).

"We are the only one in the top 10 industrialized nations that doesn't have health care," said American Psychotherapy Association member Julia Bays, M.Ed., LPC, of Alva, Oklahoma. "You can't let people die; mental illness kills people, too."

When it comes to paying for reform, two ideas now under discussion among policy makers garner initial majority support. Fifty-seven percent of the public say they would support "having health insurance companies pay a fee based on how much business they have" and 59 percent would support "having health insurance companies pay a tax for offering very expensive policies." In both cases, Republicans are evenly divided while Democrats and political independents tilt in favor. The poll did not test arguments for and against the policies (Kaiser Family Foundation 2009).

"Right now, the state governments are restricting competition by a system of arcane laws that tie the hands of insurance companies," said Dr. Brown, who is a member of the American Psychotherapy Association. "President Obama is saying we're needing more competition and [yet] his end goal is to have a universal single-payer health care system that the government runs. Depending upon what data source you use, somewhere between 78% and 84% percent of people who currently have health insurance are happy with their health insurance company. Why have the government control over one-sixth of the economy for just 10 to 12 million people who are uninsured?"

Improving Accessibility

One in four Americans suffers from a mental or substance use disorder each year; 50% during the course of their lifetimes, according to Dr. Hoyd Sederer, medical director for the New York State Office of Mental Health, who spoke out in a column in the Huffington Post (2009).

Although mental and substance abuse disorders are more common than diabetes, heart disease, and cancer, only 40% of people get any treatment for these common, painful and potentially disabling conditions. "Worse still, quality is typically abysmal with a highly noted national study showing that only one in eight people with mental health problems in primary care settings (the major site where people go for care) get 'minimally adequate care,'" Sederer said.

"This probably goes without saying, but then again, it should be said loud and clear: research has long determined that, for example, 85% of visits to a primary care physician are related to stress; stress is the number one contributor to most health problems; billions of dollars each year are lost in productivity due to 'presenteeism,'" said Paul J. Schweinler, LMHC, NCC, DAPA, Coral Springs, Florida. "I believe the major impact on the health care crisis is the lack of support and encouragement for mental health. Psychotherapy doesn't only treat symptoms, it resolves the issues."

Psychotherapists and other mental health professionals celebrated when the Mental Health Parity and Addiction Equity Act were signed last October. "The Mental Health Parity Act passed and was supposed to have regulation by October 3," said APA member Linda D. Whitten Stalters, MSN, RN, MTAPA, chair of the Schizophrenia and Related Disorders Alliance of America. That was delayed until January 10, and there are loopholes with the parity--it's only covered for employers with 50 employees or more."

Health care systems are looking for new ways to make mental health more accessible. "Major systems are beginning to shift, and I think we are going to be integrating psychologists, therapists, social workers, and advanced practice nurses with strong psychological clinical training to step up and be in medical offices," said Maria E.J. Kuhn, a psychotherapist and owner of the Geneva, Illinois-based Kuhn Counseling Centers. "There is a tremendous opportunity rising--if we don't get too rigid in our traditional ways of thinking."

Kuhn said major medical centers are already trying to figure out how to incorporate mental health professionals into their traditional medical models. "The federal government and the VA will probably do it first, but I am also seeing major hospital associations getting into it," she added.

A nationwide effort to coordinate mental health with primary care is already underway, the Philadelphia Inquirer recently reported. The idea is to give simple interventions in 15- to 30-minute visits that will address behavioral issues ranging from stress to traumatic reactions that often go untreated. The goal is to help lower the costs of health care in the long term. Some clinics have coupled licensed social workers with their other clinical staff; the mental health experts provide services while patients and family members receive physical care. Insurers, however, have been slow to pay even for brief visits, so the model is catching on, mostly in settings where the same entity provides insurance and medical care (Kaiser Health News 2009).

Carol A. Gleason, MM, RN, CRRN, CCM, LRC, BCPC, chairman of the Case Management Society of America's Public Policy Committee, advocates the implementation of case managers and said that case management programs must be sponsored as part of the health care initiatives moving through Congress.

"Case managers are licensed professionals with the experience to support individuals and their families," she noted. "Case managers provide services that are crucial to saving costs and improving quality in the health care system, especially with the majority of health care dollars being spent on chronic illness. With such a fragmented health care system, case managers provide critical services to help patients and their caregivers navigate, coordinate, and transition through a dynamic approach to better achieve their health care goals" (CMSA 2009).

Costly Infrastructure

With the promise of changes on the horizon, Congress and President Obama are also concerned with the infrastructure needed to support a reformed health care system. The President said all Americans' medical records are to be computerized within the next five years, noting that electronic records system will improve quality, lower costs, and save lives by reducing preventable medical errors.

There is a myriad of obstacles to moving the nation's health care system--and its abundance of paper records--into the computer age. The President earmarked $19 billion in the American Recovery and Reinvestment Act of 2009 to incentivize doctors and hospitals to adopt electronic record keeping and, by 2014, every organization is supposed to move toward electronic health records. The cost and complexity is daunting and will pose a challenge and expense for non-physicians.

"I do not see how government health care, or for that matter the insurance conglomerates, will help the clinical counseling profession," said Fredderick J. Nastri, MA, LCPC, in Williamsport, Maryland. "There is already too much paperwork and too many roadblocks for professionals to overcome attempting to recover their fees. One must hire a billing specialist just to recover billable revenues. I accept EAP referrals from a HMO-like provider. I have little paperwork and fees are okay. I also do not take any insurance in my practice and by keeping the paperwork to a minimum I can keep fees lower and offer clients CCC--Complete Confidential Counseling. No third parties, no computer billing where names are in cyberspace ... etc. Clients are receptive and like that there is no "paper trail" for their counseling. So, in all, I feel the system probably is better as it stands now with some better oversight of potential fraud. Sadly, the lesser of two evils is where we are now and with government I can only see more fraud, waste, and mismanagement."

Advocates of electronic record keeping say better documentation will help system auditors determine the value of services provided. "Performance measures of ongoing treatment is going to be a huge issue," said Clifton D. Croan MA, LPC, DAPA, and CEO of Enigami Systems Inc., a health information technology company located in Denver. "With the different ways that HIT [Health Information Technology] is tracking symptoms, that is going to be a very direct measurement of what we as clinicians do."

Today's health care is evidence-based, and psychiatry needs more research to qualify that it is evidence-based care, some professionals say. "It means a lot more documentation, and they are going to expect a lot more outcome documentation from the patient and the clinician," Stalters said. "Researchers will have to devise valid research studies and they will have to show how they can reduce costs to the system." Clinicians may have to "rethink the art of diagnosing" since insurance companies have shown interest in Axis I and Axis II as well as using DSM [Diagnostic and Statistical Manual of Mental Disorders] as a diagnostic tool, Kuhn said.

"My fear is that we are not at the table and the big boys are at the table making choices," Hixson said. "I wish we had someone in Washington. I know the APA [American Psychological Association] has and the social work people have people there. We need someone to be part of that, outside of the phone calls and e-mails we sent to our representatives."

Looking Forward

Today, about 15% of the U.S. population lacks health care coverage (Parente & Bragdon 2009). "People forget that when you have a large population that is simply not insured, we all pay for them anyway," Kuhn said. "If we could get them insured, then I think the next issue with health care will be really holding people accountable for their health choices, where right now, we don't do that.

"It's all about values and priorities," Hixson stated. "We pay enormous amounts of money for oil, and we give billion of dollars to corporations and trillions of dollars in foreign aid to other countries. But if little Joey needs a shot or a $10,000 operation, he can't have it. It's too costly. In the end, it is about national priorities."


APA (2008, October). APA Practice Organization. The Wellstone-Domenici Mental Health Parity Act of 2008: Questions and Answers for Psychologists.

CMSA (2009, August 27). CMSA Announces New Model Act Supporting Case Management Programs. Press Release. Retrieved November 6, 2009, from http://www.cmsa.org/PolicyMaker/Health careReform/tabid/445/Default.aspx

Kaiser Health News (2009, September 29). New 'Movements' Seek to Introduce Preventative Mental Health Care in New Settings. Retrieved October 19, 2009, from http://www.kaiserhealthnews. org/Daily-Reports/2009/September/29/care-models.aspx

Kaiser Family Foundation (September 29, 2009). Public Support For Health Reform Increases in September, Reversing Summer Declines as Congress Takes Up Legislation." Press release. Retrieved September 29, 2009, from http://www.kff.org/kaiserpolls/ posr092909nr.cfm. Retrieved 2007-11-23.

Parente, Stephen T. & Bragdon, Tarren (2009, October 17). Why Health Care is So Expensive in New York. Wall Street Journal.

Sederer, Dr. Lloyd (2009, September 24). Where is Mental Health in Health Care Reform. Huffington Post. Retrieved September 24, 2009, from http:// www.huffingtonpost.com/lloyd-i-sederer-md/ whereis-mental-health-in_b_295776.html&cp
Health Care Reform Proposals

Features          Resident Obama's       House Democratic
                  Proposal               Bill: Affordable
                                         Health Care for
                                         America Act

Who is Covered    All Americans          96% of Americans

Cost              Obama said in a        The Congressional
                  September speech       Budget Office
                  that his plan would    estimates $1.2
                  cost around $900       trillion.
                  billion over 10

How It Is         Costs will be paid     An income tax
Paid For          by cuts to Medicare    surcharge on high-
                  and taxes to high-     income individuals
                  value insurance        and reduced
                  plans. Would           spending for
                  dedicate $630          Medicare and other
                  billion over 10        programs would off-
                  years toward a         set the pricetag,
                  Health Reform          bill leaders say.
                  Reserve Fund in

Requirements      Supports an            Individuals will be
for Individuals   individual mandate     responsible for
                  as long as hardship    obtaining coverage
                  waivers were           or face a penalty
                  provided.              capped at 2.5% of
                                         adjusted gross
                                         income above a
                                         specified level.

Requirements      Businesses with more   Employers will have
for Employers     than 50 employees      the option of
                  would be required to   providing insurance
                  offer coverage or      or contributing
                  pay a fee.             funds on their
                                         behalf, Small
                                         employers are

Mental Health     Covers mental and      Covers behavioral
Coverage          behavioral health      health treatments
                  care.                  and mental health
                                         Establishes training
                                         program for
                                         behavioral health

Public Option     Offers a public        The Health Insurance
                  health insurance       Exchange, starting
                  option to provide      in 2013, will be
                  the uninsured and      financed by
                  those who can't find   premiums. Insurance
                  affordable coverage    companies can't
                  choices.               decline coverage due
                                         to preexisting

Details           Ends discrimination    Insurance companies
                  against people with    can no longer
                  preexisting condi-     exclude coverage due
                  tions.                 to preexisting

Features          Senate Democratic Bill: America's Health
                  Future Act

Who is Covered    94% of Americans

Cost              Less than $900 billion over 10 years.

How It Is         Fees on insurance companies, drug
Paid For          makers, and medical device manufactures.
                  Fines for people who don't purchase
                  premiums; tax levies on insurance

Requirements      Everyone will get coverage through work,
for Individuals   a government plan, or their own.
                  Individuals would be able to buy their
                  insurance from an exchange created in
                  their state, which would be created in
                  2010. Premiums would be capped at 13% of
                  the buyer's income, with the rest of the
                  costs paid by subsidies.

Requirements      Requires businesses with more than 50
for Employers     employees to pay fees going towards the
                  aforementioned subsidies. The maximum
                  possible fee would either be $400 per
                  full-time employee or the average cost
                  of the subsidies a firm's employee's
                  take in multiplied by the number of
                  those receiving them.

Mental Health     Covers behavioral and mental health
Coverage          services.

Public Option     No public plan.

Details           Bans insurance companies from
                  restricting coverage based on
                  preexisting conditions. The insurance
                  premiums can take into account tobacco
                  use, age, family size, and geographic
                  location. Insurance companies would also
                  be forbidden from setting up lifetime
                  or annual caps that specify a maximum
                  amount of care that customers can

Sources: Kaiser Family Foundation, Wall Street Journal.

Paying for health
care overhaul

Congress is considering several
ways to pay for the health care
overhaul. How Americans feel
about some of the options:

Tax companies on the money they
spend to offer health insurance
to employees

Favor          17%
Oppose         74%
No opinion      8%

Increase income taxes paid
by people who earn more than
$250,000 a year

Favor           57%
Oppose         136%
No opinion       6%

Increase income taxes paid
by all Americans

Favor           18%
Oppose          75%
No opinion       8%

Tax sugary soft drinks

Favor           44%
Oppose          49%
No opinion       6%

NOTE: Figures do not total 100 percent
due to rounding or because 'Don't know'
response not included

[c] 2009 MCT

Source: AP poll of 1,502 adults, Oct. 29-Nov. 9,
2009; margin of error: +/-2.5
percentage points

Graphic: Judy Treible

Note: Table made from bar graph.
Gale Copyright: Copyright 2009 Gale, Cengage Learning. All rights reserved.