The Assembly or parliament of the American Psychiatric Association (APA) met in Washington DC just three days after the federal election, and not surprisingly there was a lot of discussion about “health care reform.” There were attacks on the current U.S. system and expressions of dissatisfaction from many psychiatrists.
When such discussions take place, almost inevitably suggestions are made about moving to a single-payer system and looking at how health care is funded and managed in Canada. As a Canadian representative to the APA Assembly I have often been asked to make presentations and to comment, so some readers might have heard or read what I have said in the past.
But let me briefly tell a story my favorite rabbi used to tell often. He was leaving his house one Sunday when his young son said to an older sister, “Where is Daddy going?” “Daddy is going to Pittsburgh,” replied the sister. “And why is Daddy going to Pittsburgh?” “He's going to give a talk.” “What is he going to say?” “Oh, you know, he says the same thing wherever he goes.” Rabbi Wein used this as the entry to his talk saying, “I do say the same things, not because there is nothing new, but because so many of the ‘old’ things are worth repeating and perhaps looking at in a fresh way.”
A “single-payer system” is a euphemism for what we hav in Canada right now, which is socialized medicine…
A “single-payer system” is a euphemism for what we have in Canada right now, which is socialized medicine, and which many members of the public and many doctors including the current and immediate past presidents of the Canadian Medical Association want us to move away from.
In the Canadian system health care is managed by the provinces, not by the federal government, and is funded by us, the taxpayers. The provincial governments set up government controlled insuring agencies that pay most doctors directly. A very small number of psychoanalysts still bill their patients directly, but they are only allowed to bill at the government-set rate for psychotherapy. There are a few procedures such as cosmetic surgery, for which doctors can bill completely outside the system, and independent assessments for legal or insurance purposes can also be billed individually, but again these only apply to a small minority of physicians.
The advantages of such a single-payer system are that a doctor need only send in to the one (government) insuring agency documentation of services provided once a month, and the doctor will usually be paid in full. The paperwork/administration for both government and doctor is much lessened.
For patients, the biggest advantage is that they have unlimited access to medical care at no apparent immediate cost to themselves at the time of the service.
However, access does not necessarily mean prompt access, and socialized systems are notorious for long waits for immediate services such as in emergency rooms, but more frequently long waits for appointments with specialists, for investigations, and for elective surgery.
There is, of course, a cost; taxes are much higher than in many other countries, and a number of the provinces including Ontario, the largest, have an additional prorated “health tax,” which means that higher income earners pay even more than everyone else.
The Clinton administration tried to introduce significant health care reform with proposals that many people saw as being socialistic. So let me make it clear; a single-payer system for a country the size of the United States can only mean government as the “payer,” and that inevitably means government control—which is the case for any socialized system.
Furthermore, Americans have to understand that government control inevitably comes not just with lower rates of pay, but also with increased restrictions and regulations and increased powers for your licensing and disciplinary bodies. Anyone who denies this is simply ignorant of the histories of socialist administrations all over the world.
The implications for psychoanalysts and for psychodynamic psychotherapists are considerable. The notion of billing your own patients directly and preserving the tight boundary of the patient-doctor interaction and the autonomy and individual responsibility of the patient become progressively eroded. The remuneration falls more and more below what it should be according to the experience, reputation, longer training, greater competence, and contributions to the profession of the therapist. It falls far below what people of comparative experience, education, and qualifications in other professions can earn, even though those other professions carry far less responsibility for people's lives.
Joseph Berger, M.D., is a Distinguished Life Fellow of the APA, has served as a Board Examiner for the ABPN, and is the author of several papers as well as the textbook, The Independent Medical Examination in Psychiatry.
In our current system a very experienced mature therapist with many years of experience, teaching, and publications, is paid exactly the same rate per session as the young person who graduated yesterday afternoon.
When there is just one payer—government—payments are subject to political whim and to the outcome of intense political fighting between different departments of government over slices from the same budget pie. Each department claims that its needs are “unique,” “special,” and definitely “more important” than any other.
Some frustrated American psychiatrists have been looking with envy at the Canadian system. I have been telling them that many Canadians look with envy at the level of excellence of American medicine, which at the top level is unequalled anywhere in the world. Canadians look with envy at the degree of freedom that still remains in the American system, at the comparative absence of the long delays and waits characteristic of the Canadian system.
I do emphasize that every civilized society should have a publicly funded universally accessible health care system. But it is vital to preserve the private alternative which allows the freedom to compete, innovate, and excel.
I understand that the American system needs considerable serious improvements, but the Canadian system is not the way to go.