The national health care reform plan has received many obituaries. Universal coverage, along with the Clinton plan, has met its demise. Obviously, the political timing was bad, and the complexity of the present U.S. system of health care rendered the plan extremely vulnerable. It drew intense response from every quarter, including The American. The organization retained Daniel Leach, a highly qualified lobbyist whose firm helped us educate legislators about our patients' needs. The Clinton bill easily matched the nation's present health care system in complexity and unwieldiness, and an even more gargantuan alternative bill met similar opposition and collapsed. The latter could have been presented to Congress as over seventy separate bills, each with numerous components.
Complementing our own lobbying efforts were those of others who, though they spoke with different voices, were yet in harmony with our goals. In the battle to educate Congress we at times bumped into one another, but for the most part all went well. In fact, the results have been more positive because our voices have risen in chorus. We have made it clear that any system of health care that emerges must protect privacy, confidentiality, and the right of patients and therapists to work together completely outside the system. Parity of coverage for mental illnesses vis-à-vis medical/surgical illnesses was approached or accomplished in almost all the bills pending when the reform plan collapsed.
What have we learned? Psychoanalytic clinicians have proved able to speak effectively about their provision of needed services. Younger analysts in particular, who are on the threshold of their careers, have shown themselves to be even more articulate and energized than their senior colleagues. The work of these young analysts on the Committee on Government Relations and Insurance has been extraordinary. Similarly, candidates have become active on the issue, because their futures are most at stake. Those of us involved in training must listen to their expressions of concern. The questions they raise about the viability of psychoanalysis, were it to exclude itself from any future health care system, beg for answers. Information on the impact of insurance industry “oversight” must be gathered so that legislators at the state and national level can be convinced of the importance of
privacy, confidentiality, and continuity in the therapeutic relationship.
We have also learned that threats to the viability of analytic practice and to the provision of analytic treatment must be addressed using a coalition approach rather than going it alone. Legislators are ever more aware of why psychoanalysts want fee-for-services and point-of-service options in third-party situations. There is also increasing awareness that the insurance industry must be reined in; one national legislator has characterized managed care as “an unbridled private bureaucracy.” While the future of national health care reform is extremely uncertain at present, state legislatures are becoming increasingly active in the health care arena. Already many experiments have been enacted at the state level, and more will be seen in the coming years. Incremental reform seems to be the emerging pattern, a piecemeal, patchwork process of legislative change with the potential to make matters even worse for our patients. The unbridled private bureaucracy that has been sold to U.S. consumers under the guise of quality control and cost containment will go unchecked and become worse. Would any of us tolerate the flagrant intrusions visited upon us by this behemoth if they came at the hand of a government agency, even the IRS?
What to plan for the future? On a national level we will continue to monitor the incremental changes impacting our patients and our work. For this we will need the skills of our lobbyist, and we hope to receive organizational support for retaining his services.
Coalition building will be a major focus for the next decade. We have seen its past effectiveness and will need it all the more as the struggle is engaged in state legislatures and regulatory boards across the nation. A coalition has already come together in Michigan, and we hope that our involvement in the Psychoanalytic Consortium nationally will encourage similar collaborative efforts elsewhere. Over the past decade The American has supported CGRI's network building, which must now be stepped up, especially in states in which major reform initiatives are imminent. Despite the enormous logistical problems, recent experience leaves me hopeful regarding the success of future collaborations. During the past session of Congress, I realized how articulate we have become as we risked exposure outside our offices. It is extremely gratifying to see leadership and members working so effectively to support psychoanalysis. And of course we speak out on issues in a style quite different from that of professional lobbyists. The latter must be gregarious, adversarial, and extremely competitive if they are to be effective, qualities which may offend some of us. I have learned, however, to view these differences as complementary; the different approaches have melded nicely to effect desired change.
Legislative and bureaucratic matters, both state and national, are realities for The American and its members. We were wise to remain active this past year and to involve ourselves in the public arena. We are far better prepared now for the next round of the battle to preserve psychoanalysis, for which we will need the help of the entire membership. The difficult task before us will be made easier once we have the national patient data Norman Doidge is currently collecting. To hasten that event, I urge all members who have received his questionnaire to respond immediately.
Arthur J. Farley, M.D., chairs The American's Committee on Government Relations and Insurance.