In Bob Pyles's column, “Lessons from Germany: Single Payer No Panacea” (TAP 40/4), he assumes incorrectly that Germany utilizes a single payer national health service (Kächele, Richter, Thomä and Meyer, 1999) and concludes there is little difference between a single payer and our multi-payer system. Moreover, taking a narrowly psychoanalytic point of view, he fails to consider our more fundamental identities as citizens.
Psychoanalysts, as citizens, should consider total health care. The United States is the only industrialized nation not guaranteeing access to health care as a right of citizenship, despite spending a larger share of our gross domestic product than any other industrial country (7.9 percent in 2004). For all the expenditure, effectiveness is poor; e.g., the United States ranks 23rd in infant mortality.
Single payer administrative costs are 50-100 percent lower than comparable multi-payer systems, and both the Congressional Budget Office and the General Accounting Office have determined that single payer coverage would provide total care for all while saving $100-200 billion per year. Those 45.8 million Americans (in 2004) not covered by any health insurance would be covered and eligible for psychoanalytic treatment, thereby challenging the longstanding criticism that analytic treatment serves only the relatively wealthy.
In conclusion, as analysts we should look beyond our narrow professional identity. Clearly, a single payer plan, such as California's, Maine's, Massachusetts's and Vermont's, offers advantages both in comprehensive health care and in psychoanalytic treatment compared to our current multi-payer system.
Joseph Schachter, M.D., Ph.D.
I am puzzled by Joe Schachter's letter, since his comments seem largely unrelated to anything I said in the article. I was trying to make two points:
No matter what health-care system is utilized, whether it is public, private, or a mix thereof, economic pressures will tend to drive down the quality of care. The only way to achieve and insure continuing quality health care is for us as individuals, and as professional associations, to actively advocate for our patients and our profession.
Some advocates for a “single payer” in this country tend to have a rather utopian (and naïve, in my opinion) vision that simply establishing such a system will “fix” our badly broken health-care system. In point of fact, the kind of single payer model that we are likely to wind up with, unless we can prevent it, is one which will not only be capitated in terms of total cost of treatment, but will be administered through managed care companies. Therefore, unless we can prevent it, we are likely to have the worst of both the public and the private systems.
With respect to psychoanalysis, Schachter makes the flawed assumption that a U.S. single payer system would cover meaningful psychotherapeutic treatment. One only has to look at Medicare to find ample evidence to the contrary.
Bob Pyles, M.D.
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