The bad news was delivered on the front page of The New York Times last December: The Mental Health Parity Act of 1996-the long sought after federal law that was supposed to discourage health benefits discrimination against the mentally ill-was described as having "failed" to achieve parity because insurers and employers take advantage of loopholes. Despite the critical nature of the report, however, no one from the American Psychiatric Association, not a single psychiatrist for that matter, is quoted in the article.
Although there may be numerous reasons why the story did not include a comment from the psychiatric profession, critics nevertheless point to the absence of an APA voice as symptomatic of a broader problem. With time running out on a host of issues critical to psychiatrists and the patients they treat, there is mounting concern that outmoded approaches to influencing Congress and public opinion mean the APA message won't have a strong political punch. While efforts are underway to meet the looming challenges, the question remains whether planned reforms could prove to be both too little and too late.
After years of debates over national health policy, it seems as if everything is suddenly coming to a head. For example, congressional activity directed at medical privacy-a hot-button issue for every segment of the health care system-is certain to crest during the next several months. Unless Congress enacts legislation by August, regulations promulgated by the Department of Health and Human Services will come into effect by default, a prospect feared by most psychiatrists who believe the rules won't adequately protect patients against wholesale disclosures of medical records. Meanwhile, there is mounting public support for legislative fixes to health care woes, including increased regulation of HMOs and insurers; enactment of a patient bill of rights; amendments to the Employee Retirement Income Security Act (ERISA) that would permit heightened oversight of health plans; and reassessments of laws affecting parity, health care reimbursements, research, physician work force issues and medical research.
For Steven Mirin, M.D., the APA's medical director, there is little question that the organization is up to the task. "One of the great strengths of the APA is the credibility of the Division of Government Relations with a substantial number of the members of Congress-both the House and the Senate," Mirin told Psychiatric Times. "Credibility is something that is built over a long period of time, in terms of relationships, of being able to deliver…information that turns out to be the correct information, and the ability to work with members of Congress and their staffs in drafting legislation, as well as simply responding to it."
Rodrigo A. Muñoz, M.D., the asso-ciation's president, said, "We are about to announce the new APA, one that is member-oriented and devoted to activities that give priority to advocacy for our patients and for our members. The most important two activities that represent this advocacy are government relations and public affairs. In order to give more emphasis to these two functions, we will get them together under the same APA component to permit us to better interact with those who are likely to help us."
Currently underway is an internal restructuring that Muñoz said will create "a seamless progression of actions from the members, to the district branches, to the assembly and to the board." The idea, ultimately, is to allow staff to rapidly mobilize APA members when it is time to move on legislative initiatives.Grassroots Organizations
An initial effort to create that seamless progression stalled, pitting members keen on developing a grassroots infrastructure against an APA insistent on doing things its own way.
"Psychiatrists were telling us they wanted to know what to do and when to do it," said Deborah C. Peel, M.D., an Austin-based psychiatrist who will be the next president-elect of the Texas Society of Psychiatric Physicians. She is also a consultant to the APA's Joint Commission on Government Relations. "People are hungry for information about how to help our patients, when and how to intervene in the patient protection legislation process, and who to call. That is not coming out of the APA."
Initially encouraged by some APA officials to initiate a grassroots campaign, Richard S. Epstein, M.D., a Bethesda, Md., psychiatrist and an APA trustee-at-large, along with Peel and Ronnie S. Stangler, M.D., a Seattle psychiatrist, created an e-mail list that could immediately notify psychiatrists when it was time to turn up the political heat on both federal and state legislators. Epstein hoped that the network, with nearly 9,000 subscribers, would be "a powerful voice for our patients and profession."
But in the end, the APA told the group that it could not operate under the association's banner, even though the group promised to disseminate APA policies and positions on legislative issues. Although what became the Psychiatric Grassroots Network (PGN) still coordinates with the Division of Government Relations to come up with stands on health care issues, it is nevertheless a free-floating effort operating without the APA's imprimatur. In an interview with Psychiatric Times, Epstein lauded the efforts of the association's lobbying and public relations staffs. However, in order to fulfill a campaign promise to increase psychiatry's political influence, he ended up having to act on his own.
"I did this as a way of demonstrating that there are new ideas," Epstein said. "We need to advocate for our patients and our profession, and we need to be very vigorous about it by working together at a grassroots level."
Ronald A. Shellow, M.D., a Miami-based psychiatrist who has served as the APA's chair of the Joint Commission on Government Relations since 1993, however, said that the APA has been "exceedingly successful [in terms of government relations]," and vows to "continue [the activities] as well as we have been." Nevertheless, even he acknowledged that grassroots organizing requires more attention. "One of the problems, and this has been a problem all through medicine, has been that the profession is unable to mobilize physicians, including psychiatrists, to raise hell with their legislators."
Mirin acknowledged that the "whole issue of a grassroots network is absolutely crucial," adding that for any grassroots network to be useful to the APA, its district branches and its membership must represent a coordinated effort.
"State issues impact federal legislation. Federal legislation impacts the states. We can't have these two entities disconnected. So our goal is to build out a grassroots network that basically promulgates APA policy," he said.
In line with that goal, the APA has a public policy advocacy section on its Web site. It publishes newsletters and issue statements about federal, state and regulatory issues impacting psychiatry and health care. As part of that section, APA members can fill out a form to join the Division of Government Relations Grassroots Network. The network has a membership of 2,500 of the 40,000 APA members.