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At first glance, this book seems only tangentially related to the concerns of the psychoanalytic practitioner, but that actually is not so. It consists of a rather lengthy white paper by David Upton on the various issues involved in the coverage of psychiatric illness by group health insurance plans, including but not limited to a National Health Insurance scheme, followed by commentaries by experts in the field.
As Milton Greenblatt observes, the recent emphasis by the Reagan administration, and presumably by succeeding ones, on medical cost containment and on budgetary constraints in nondefense areas makes a comprehensive National Health Insurance plan extremely unlikely in the forseeable future. Then, too, private health insurers are increasingly unwilling to provide more than short-term psychiatric benefits, with an emphasis on inpatient coverage. Finally, newer systems of mental health care delivery, as in health maintenance organizations (HMO's), stress brief, symptom-oriented treatment with specific exclusion of long-term intensive psychotherapy and psychoanalysis.
Yet Upton's essay raises vital issues which have impact on the practice of psychoanalysis and on future advances in its theory and technique, since they depend on the accumulation of psychoanalytic data. If the number of patients undergoing analysis decreases markedly, the richness and vitality of psychoanalytic thought will suffer. The number and quality of analytic candidates also will decline if there is little opportunity to practice analysis after the years of arduous preparation involved.
Paradoxically, the cost of the psychotherapies, including psychoanalysis, when compared to the cost for all health care spread over the population at risk is extremely low. For example, a 1973 study of the Blue Cross/Blue Shield Federal Employees Health Benefits High Option Plan (which covered unlimited psychotherapy or psychoanalysis at an 80% level) revealed that only 0.63% of all the enrollees received