In America, psychoanalytic treatment has become the exception among psychological treatments, because it insists on a humanistic approach that draws a distinction between the patient and symptoms, always keeping the patient in the foreground. Concordant with the Enlightenment, the practice of medicine has also been humanistic, but less so over the past 50 years due perhaps to the exigencies of universalized payment systems.
The Medicare Act (1965), Employee Retirement Income Security Act of 1974 (ERISA), the Health Insurance Portability and Accountability Act of 1996 (HIPAA), and most recently the Patient Protection and Affordable Care Act of 2010 (ACA) were enacted to help reduce the cost of health care and improve access for the uninsured, but those laws also encumbered basic freedoms. Medicare prohibited eligible patients and clinicians from entering into private contracts outside of Medicare, undermining confidentiality for Medicare-eligible patients and hamstringing their clinicians. Under ERISA, patients lost the right to sue managed care organizations beyond the cost of the treatment in circumstances where necessary treatment was denied. Under HIPAA, patients lost the right of consent to disclosures of confidential information for manifold purposes. Finally, under the ACA, the principles of consent and conscience have been supplanted by mandates that eliminate patient confidentiality with regard to government.
One of the goals of recent legislation was to increase access to health insurance by making it more affordable, saving money. Premiums briefly plateaued in 2011, but insurance premiums are predicted to rise through 2025 at an accelerating rate.
It is difficult to assess whether access to health care has improved. On the one hand, many previously uninsured patients are now insured. But many patients, despite promises to the contrary, have lost their private insurance and doctors.
Physician Ezekiel Emmanuel, one of the architects of the ACA, said in Reinventing American Health Care that by 2025, “fewer than 20 percent of workers in the private sector will receive traditional employer-sponsored health insurance,” suggesting that 80 percent will be enrolled in the exchanges or face a tax increase (individual mandate). S&P Capital IQ, part of McGraw Hill Financial, says the news is more dire for employer-provided health plans. They project that by 2020, 90 percent of American workers who are currently insured through their employers, will either lose their insurance and be forced to join the exchanges, or else pay tax penalties to the IRS. If these estimates are remotely accurate, this is troubling news for the future of psychoanalytic practice, especially for those psychoanalysts who rely on out-of-network, fee-for-service reimbursement from private insurers. As more patients lose their private insurance and enroll in the ACA, this will mean that there are fewer potential patients who could be treated out-of-network.
Graham L. Spruiell, M.D., is co-chair of the Committee on Government Relations and Insurance and a member of the Program in Psychiatry and the Law, Massachusetts Mental Health Center.
During the past 50 years, there has been a dramatic shift in the philosophical assumptions underlying health care in this country, away from the patient towards symptoms, the rating of symptoms, and the reified diagnosis of symptoms. Numeric scales measure the intensity of symptoms before and after treatment, and a determination is made about whether a particular “evidence-based treatment,” among many possible treatments, is effective and affordable. If so, this information is integrated into treatment guidelines and algorithms.
This automated approach to health care is the operational standard of the Veterans Administration, having received the IT honor, “Most Wired” for two consecutive years. Yet despite technological innovations and a budgetary increase of 300 percent since 2000, more than 57,000 veterans have been waiting more than 90 days to be seen. Additionally 64,000 veterans enrolled, but never received appointments, in some cases resulting in fatalities.
Of 22 million veterans, only 9.1 million are enrolled in the VA system. In 2010, a national survey of veterans revealed that only 16 percent of veterans used the VA as their primary source of health care, and 35 percent said that they used the VA as a “safety net,” while 32 percent said that they had no plans to use it at all. The remaining percentage used the VA for some of their care, prescriptions, specialized care, or in some other way. If the results of the survey of 2010 are applied to 2014, of the 9.1 million current enrollees, only 1.5 million veterans are currently using the VA as their primary source of health care while 7.6 million are not. The Department of Veteran Affairs budgeted $150.7 billion in 2014 for approximately 1.5 million such veterans at a cost of $100,467 per veteran.
Enrolled veterans suffer long waits before being seen; sometimes they are never seen. Moreover, veterans are committing suicide in record numbers. For male veterans under the age of 30 (2009–2011), there was a 44 percent increase in the numbers of suicides; for women veterans, the suicide rate increased by 11 percent. It would be simplistic to say that long waits caused the increase in suicides, but there have been whistle-blower reports alleging that suicides have occurred while veterans were waiting for treatment. Apart from the dramatic difference in scale, some argue that if you want to see the future of government-run health care in this country, consider the Veterans Administration.
Whether the ACA is maintained in its current form, modified, repealed completely, or becomes a single-payer system, the philosophical transformation of health care has largely already happened with ERISA and managed care. In redefining the therapeutic relationship from the clinician-patient relationship to the clinician-patient-insurer relationship, the insurer became superordinate to the clinician and the patient. The ACA worsened this breach of boundaries with the construct of the clinician-patient-insurer-government relationship, whereby the government became superordinate to the insurer, who was already superordinate to the clinician and patient.
In this scenario, rather than a clinician recommending a course of treatment in collaboration with the patient, the clinician works as an employee at the behest of the insurer and the government. Health care is no longer related to the freedom inherent in the clinician-patient relationship and the proper right to determine the direction of the treatment, but rather entails very gradual acquiescence to an authoritarian, mechanized, compliance-driven, and sometimes corrupt form of health care in which the clinician and the patient have the least control.
This is quite different from the therapeutic relationship of psychoanalysis in which the goal is consent between the psychoanalyst and the patient about the direction of treatment. In psychoanalysis, treatment authority resides within this relationship, having little to do with algorithms or evidence-based principles. Psychoanalytic treatment regards the patient as a sovereign agent with rights, including confidentiality. The interests of the government, insurer, society, family, coworkers, employers, and other collectives merit due consideration, of course, but the patient is absolutely primary. It is not possible to maintain that the interests of the individual patient are primary while simultaneously acting as if the interests of collectives are primary.
Psychoanalysis is exceptional, not because it is better than other mental health care disciplines. Rather, psychoanalysis is an exception in its philosophy and practice. In marked contrast to psychological disciplines that focus on collectives and measurables, psychoanalysis posits that beyond neurotransmitters and behaviors, of which there are many, a patient is one and immeasurable: a sovereign body, mind and spirit, whom we should treat accordingly.