Late in the morning session of the Executive Council meeting of May 19, after reports from the Executive Committee and the Board on Professional Standards, President Bernard Pacella turned the Council's attention to the pending national health care legislation and The Americans bifocal view of strategic priorities in that arena.
Norman A. “Drew” Clemens, in his final presentation as chair of the Committee on Government Relations and Insurance (he leaves that post to assume speakership of the Assembly of the American Psychiatric Association), introduced attorney-lobbyist Daniel Leach, retained a few months earlier to represent The American's official views to members of the House and Senate. Leach reported having spent fifty-five of the last sixty days on Capitol Hill educating legislators about the need to protect the environment necessary for quality mental health care.
Just the day before, he noted, the Senate Labor and Human Resources subcommittee on health, under Senator Edward M. Kennedy, had voted for the nondiscriminatory provision of benefits for psychoanalytically oriented psychotherapy. This would enable the financing of psychotherapy on the same basis as other medical care. Leach also reported that the House Ways and Means subcommittee on health, chaired by Congressman Pete Stark, passed its own version of health care reform, a bill providing unlimited psychotherapy sessions with a 50/50 copayment feature. Universal coverage would be accomplished by extending Medicare to the indigent. Other committees had not yet written bills, but all committees expected to contribute to the eventual legislation were meeting, preparatory to the “marking up” of their versions of the bill.
Clemens then asked the Council to approve the CGRI report, which included a statement drawn up through prolonged electronic negotiations among Robert Pyles of the Coalition for Patients' Rights (CPR), President Bernard Pacella, and himself, with additional input from Robert Cummings of Southern California and other interested parties. When CGRI reviewed the agreement at its meeting the previous day, it voted to modify item 4, a change opposed by CPR. The original agreement negotiated between CPR and CGRI spoke of the priority of lobbying for the right to contract privately, within or without any system of care. The new wording would allow Leach the latitude to present arguments to legislators for the inclusion of psychoanalysis or psychodynamic therapy in health care coverage without first eliciting their agreement to statutorily guarantee the right to private contracting.
Pyles led CPR opposition to the change and spoke of an impressive outpouring of support for the group. It has been successful in raising funds, he noted, and has been endorsed by a number of societies across the country, as well as by groups outside The American. James Pyles, attorney-lobbyist for CPR and Robert Pyles's brother, told the Council of his presentations to legislators. Strategized with CPR, these talks are intended to educate lawmakers about the nature of the psychotherapeutic interaction. Some effort is required to make certain they understand that psychoanalytic therapy is different from most other medical treatments. The instrument of healing, it must be
stressed, is the relationship between patient and analyst, and since that is not supportable in health plans, it is vital that the right to private contracting be preserved, enabling those who may benefit from psychoanalytic therapy to do so.
Robert Pyles reported that responses from legislators have been positive. Only when it is understood by a legislator that the managed care environment is hostile to any procedures of depth does CPR even approach the issue of inclusion in health care plans. CPR wanted this priority of approach inscribed in the agreement, whereas CGRI wished to allow its lobbyist greater latitude in dealing with legislators considered unlikely to comprehend the conditions necessary for the proper conduct of psychoanalysis or psychotherapy.
At this point Robert Cummings entered the discussion, reprising the view held by the Southern California Society, and endorsed by many other members of The American, that analysts should opt out of any health care system on the grounds that third-party intervention precludes the conduct of a valid psychoanalysis (see TAP 28/2). Since the last Council meeting, the Southern California group has supported CPR, holding its views to be more compatible with their own. Mark Leffert of Minnesota next outlined developments in that state, where the government may be making the practice of psychoanalysis impossible. Minnesota's health plans heavily bias health care toward HMOs. The only option provided those who wish to receive medical care in another setting is to enlist in the Regulated All Payors Option (appropriately enough, its acronym is RAPO), an option that regulates the fee even in a private arrangement. This makes it essential, Leffert argued, that a law be passed at the federal level guaranteeing the statutory right to private contracting.
Discussion from the floor produced equally compelling arguments for both sides: on the one hand, that it is essential for our credibility that psychotherapy and psychoanalysis be included in any government health care system; and, on the other, that the field will survive only if the right to contract outside the system is guaranteed. For many, these goals seemed compatible. The Council then adjourned for lunch.
When the meeting resumed, Arthur Farley, Clemens's successor as chair of CGRI, proposed the reinsertion, as a preamble to the CGRI report, of a statement endorsing CPR and its aims, allowing for an organic connection between CPR and The American. The motion easily carried. A moment of high drama then ensued when the vote on item 4 was deadlocked, with President Bernard Pacella casting the deciding vote in favor of the CGRI position. The Council then voted by a wide margin to accept the twice-amended CGRI report. CPR and CGRI are now expected to work in parallel, primarily for the statutory right to private contracting, but secondarily for inclusion in whatever system of health care is eventually passed.
At the end of this protracted and exhausting exchange, the Council retired into executive session for the purpose of nominating candidates for national office and electing members to the Editorial Board of JAPA. David Hurst was nominated to run for a second term as secretary, with Alvin Frank nominated to oppose him. Four nominees were chosen for two positions of councilor-at-large: Allan Compton, Ralph Engle, Dorothy Holmes, and Harvey Rich. The following were elected to the Editorial Board of JAPA: James
Barron, Steven Cooper, Gerald Fogel, Arnold Goldberg, Judith Kantrowitz, and William Meissner. Associates elected for one-year terms are Cecile Bassen, Jane Kite, Nathan Kravis, and Humphrey Morris. Elections to the Editorial Board were carried out under a new set of rules requested by Arnold Richards, newly installed as editor of JAPA and immediate past editor of TAP. First, candidates for the Editorial Board are no longer identified as to past service on the Board; and, second, brief biographies of the nominees are distributed to councilors prior to the vote.
Treasurer Stephen Firestein next requested a vote by Council to increase the cap suggested by the Executive Committee on expenditures for The American's lobbyist from $150,000 to $175,000. The increase was approved. Firestein then presented the Executive Committee's request that the category of “life membership” be changed to “senior membership.” Dues for such members would be graduated downward over a six-year period, at the end of which no dues would be expected. This too was approved and now goes to the membership for a referendum.
Arnold Cooper, speaking for the Committee on University and Medical Education and its Resident Fellowship Subcommittee, chaired by Elise Snyder, informed the Council about the developing programs for residents and medical students. Societies were asked to designate a member to take charge of these programs locally. Because the Resident Fellowship program will expand to include Ph.D.s as well as M.D.s, increased funding is required. Snyder reported that this year sixty applications were received, of an even higher quality than in previous years. Fifteen fellowships were granted.
Robert Pyles next reported the recommendations of the Task Force on Board-Council Structure and Functions. The Council approved proposals for new bylaws specifying that BOPS committee appointments are to be made by the chair of BOPS and authorizing formation of the Coordinating Committee of BOPS and the Steering Committee of Council. Approved for referendum was an amendment whereby a vacancy in the BOPS chair will be filled by the secretary of BOPS, rather than by the presidentelect of The American, as presently called for.
Anton Kris and Robert Pyles presented options for changes in the structure of The American. One plan would add a Board of Directors and a third division that would oversee research and scientific activities. The latter, a suggestion made many years ago but set aside, was well received by members interested in research. A second plan would install a Board of Directors as a body superordinate to both Board and Council. Directors would include the nationally elected officers, three councilors-at-large, and the chair, secretary, and one Fellow of BOPS. Both plans envisage the Board of Directors as the ultimate authority in The American. In the discussion, opposition was voiced by some to the creation of yet another layer of governance. These options will next be discussed by the component societies before being taken up again by the Council.
Allan Rosenblatt next gave an update on the External Credentialing Committee. Rules changes at CORPA now allow that group to recognize more than one accrediting body per field. Rosenblatt thought that BOPS would not likely be approved as its own accrediting body, a view challenged by some. More will certainly be heard on this issue.
Finally, Marvin Margolis reported on the activities of the Psychoanalytic Consortium. He reassured the Council that the consortium has a working agreement that no action can be undertaken without the approval of the executive bodies of all four component groups. There is no danger that the consortium will undertake anything without the full knowledge and approval of The American. He concluded by noting that at present The American is a “guest” in the consortium and that a vote of the Council is required for full membership. In the absence of quorum, the vote was put off until the next meeting.