The question posed by this debate is badly timed. The premises on which the issue is based are much too speculative to allow for a reasonable decision at this point.
The real question is whether the proposal for health care reform that emerges over the next few months will have a place in it for effective psychoanalytic work. Will the provisions for cost containment create huge capitated bureaucracies, profit-driven and impersonal, that control all health care, or will the final bill allow a place for the private and sensitive adjustment of treatment to individual patient needs, and respect for the necessary conditions for psychotherapy?
We have no idea yet whether minimal reform of insurance practices, managed competition with a fee-for-service option, or a fee-for-service, single payer system will prevail. Could reform in fact ameliorate the current cutthroat managed care environment? Might we find significant improvements in the mental illness benefits? We'll know much more in a few months than we do now.
Tipper Core passionately supports full equality of coverage for mental health care, including psychotherapy; the Clinton bill would establish this parity three years after the reforms begin. Leading senators and representatives on both sides of the aisle have publicly demanded it.
According to a Parade magazine survey, a full 87% of Americans support coverage for mental illness. Do we who know the suffering of our patients want to seal them off from access to these possibilities, now and forever?
As reform proceeds, we need the unified voices and pens of our members to work for the three objectives affirmed by the Executive Council on December 16, 1993.
Nondiscriminatory coverage for mental illness that is fully equal to that for all other illnesses. In this we unite with all concerned for those who suffer with mental and addictive illnesses, which gives us a role in the negotiations. If equality is out of reach for now, then we seek the best coverage possible for psychoanalysis and intensive psychotherapy.
Protection of the environment for effective treatment against invasive, abusive, profit-driven management systems. Confidentiality, security of the treatment relationship, and patient responsibility for treatment decisions are priorities.
The freedom of individual patients and analysts to contract on a self-paying basis, if they choose, outside of any third-party payer system. This is a fundamental right in a free society, essential if coverage for services can be arbitrarily denied.
The American has hired a government relations consultant to assist us with strategy and tactics. The highest priority must be given to preserving the fundamental environment for effective treatment and to the freedom to make private, self-paying arrangements. If, in addition, we can achieve adequate and usable coverage, then so much the better. If united efforts could truly end discrimination against the mentally ill in access to treatment of genuine quality, that would be a monumental achievement.
The agitation for exclusion of psychoanalysis is misplaced. It is born of anxiety, the yearning for a simple solution, and the naive assumption that as health care providers we have the prerogative to seek the exclusion of a standard health service.
How would we present the request to exclude psychoanalysis? No matter how high-minded, our proposal would be interpreted wrongly. Presumably, we would ask that psychoanalysis be excluded from the national health security act, asserting that the proposed systems of utilization management would make effective psychoanalysis impossible. We would make this claim despite ignorance of what management system would emerge after years of deliberation by Congress, the states, national and state health boards, and delivery systems. We would do it in spite of our knowledge that fee-for-service options are under consideration and that psychoanalysis is successfully covered in some managed plans.
Regardless of what we might proclaim about protecting the integrity of treatment, our efforts to declare psychoanalysis an uninsurable service would be used to support the erroneous contentions that (1) psychoanalysis is a marginal, elective treatment of dubious effectiveness or value; (2) psychoanalysis is outside the health care mainstream; and (3) analysts are just another bunch of providers trying to escape having their greed controlled. These false perceptions would perpetuate the shameful injustice, to both our patients and our work, that the critics and detractors of psychoanalysis commit regularly in the media, and would certainly not enhance recruitment into training. Correcting the damage to the public image of psychoanalysis would be a major challenge.
Once the process of opting out is started, it may prove hard to control. The distinction between psychoanalysis and psychotherapy might be very hard to maintain, and coverage for intensive psychotherapy could be lost for hundreds of thousands of patients. Psychoanalysts would be seen as supporting, rather than opposing, discrimination against the mentally ill.
What about our younger members who are not yet part of the vocal leadership of our institutes and societies? We don't know the conditions under which the future health care provider will work. Will mental health professionals with many years of professional life ahead of them be free to practice partly inside the system (for nonanalytic work) and partly outside (for excluded psychoanalysis)? This is a vital unanswered question.
If the leadership seriously considers seeking the exclusion of psychoanalysis, at a later moment when an informed decision can be made, the issue should be submitted by referendum to the entire membership.
Does The American have the right as an association to make the unilateral judgment that psychoanalysis
Norman A. Clemens, M.D., chairs The American's Committee on Government Relations and Insurance.
should be excluded? Shouldn't other respected psychoanalytic organizations share in such a decision?
Most important, what about our patients? Many manage to pay out of pocket for psychoanalysis, but what about the distressed children and parents, the teachers, social workers, nurses, students, and others in relatively low-paying occupations who can't be helped by less intensive treatments? Can our tradition of offering some low-fee treatment suffice to meet their needs?
Exclusion is not the simple solution it might seem to some. It is an irrevocable step, not to be made hastily in a state of uncertainty. Let us set the issue aside for now and get on with the job at hand.
The American, as the oldest national organization representing psychoanalysts, certainly has the prerogative to speak for exclusion and to encourage support from other analytic organizations. Its Action Plan, however, fails to exercise this prerogative and is instead designed to be congruent with the interests of the American Psychiatric Association, while ignoring the specific divergent interests of psychoanalytic practice and education. Balanced exploration of the prospects for exclusion was dismissed from the outset on the basis of forecasts limited to gloomy, supposedly irrevocable outcomes.
We see no contradiction in advocating inclusion for psychotherapy while pursuing exclusion for psychoanalysis in order to preserve valuable standards of practice and education.
At the time of the 1993 Health Care Task Force Meetings in Washington, colleagues reported having had informal discussions which revealed to us that the specific inclusion of psychoanalysis in “basic medical coverage” was overwhelmingly opposed by elected officials and insurance, consumer, and business groups. The Action Plan's laudable egalitarian motivations are apparently dismissed by these groups as a veiled attempt to gain a higher market share of the insured mental health care industry. The possibility that psychoanalysis can gain coverage without the encumbering accountability procedures of insurance systems is so remote as to render it almost inconceivable.
The zeal to follow any minuscule hope for inclusion leads Action Plan proponents to stall. This practice is wasteful, blocking timely negotiation with health planners (1) to gain the freedom of unrestricted private contracting; (2) to explore meaningful alternatives for the funding of psychoanalytic treatment; and (3) to create a responsible independent status for psychoanalysis. This waiting in eagerness for a political compromise endangers psychoanalysis; the risk is that restrictive conditions similar to those existing now with Medicare will be imposed on all analytic treatment. The American did not prevent and has not yet found a national remedy for the Medicare inclusion trap for psychoanalysis, leaving many patients cut off from treatment. The Action Plan risks extending this trap to include all patients. Shouldn't this lesson have been learned by now?