APA and Health Care Reform: How Far the Thinking Has Come on Mental Health Issues


As the nation’s uninsured population climbs to 46.3 million and Congress grapples with health care reform, the American Psychiatric Association (APA) has intensified its efforts to advocate for a public health insurance option, insurance market reforms, changes in Medicare’s physician payment system, and preservation of parity for mental health.

As the nation’s uninsured population climbs to 46.3 million and Congress grapples with health care reform, the American Psychiatric Association (APA) has intensified its efforts to advocate for a public health insurance option, insurance market reforms, changes in Medicare’s physician payment system, and preservation of parity for mental health.

APA’s Board of Trustees voted unanimously in September to support HR 3200, America’s Affordable Health Choices Act, as the basis for health reform. One week later, APA’s medical director and chief executive officer James Scully Jr, MD, sent a “technical comments” letter to Senate Finance Committee chair Max Baucus (D-Montana), about the America’s Healthy Future Act of 2009, which Baucus had introduced in mid-September. The letter praised some provisions of the bill while criticizing others.

“There has been a fair amount of attention paid to the scaling-back aspects of the Senate Finance package, but there are still lots of good provisions in there,” said Nicholas Meyers, APA’s director of the Department of Government Relations.

APA’s lobbying strategy, he said, is to always keep a seat at the table by acknowledging the efforts made by members of Congress and by expressing APA’s appreciation and support of bill provisions that clearly benefit the profession and its patients. That is as true of the Senate Finance bill as it is of House bill, he added.

“There is no perfect piece of legislation,” Meyers contended. “Our objective is to get the strongest legislation possible to the President, and the only way I think that you can do that is to get the best bill you can out of either chamber and then work to get the best bill out of conference committee.”

Helping the uninsured

The AMA estimates that 18,000 unnecessary deaths annually are attributable to lack of health coverage. Patients without health insurance are less compliant with treatment plans, avoid preventive services, and miss appointments to manage their chronic conditions.1

HR 3200 requires all individuals to have health insurance, and Baucus’s bill requires most citizens and legal residents to obtain health insurance. A third bill-the Affordable Health Choices Act-prepared by the Senate Committee on Health, Education, Labor, and Pensions (the HELP committee) also requires individuals to have health insurance.

HR 3200 creates a Health Insurance Exchange to provide a marketplace in which individuals, families, and certain small employers can comparison shop and purchase a private or public insurance plan. Mental and substance use disorder treatment is included in the basic benefit plan, and the coverage requirements would be extended to all health insurance plans within 5 years.

Because one of the many choices of health insurance within the Exchange is a public health insurance option, Meyers was asked about APA’s support of the public insurance option.

“Our board simply looked at the overall issue of public access to care and determined it was in the interest of our patients that there is a viable public option made available to them. On that basis, the board specifically decided to support the concept of a public option without specifying exactly what that is.” The public plan is voluntary, and there are no penalties levied at physicians for not participating, he added.

Baucus’s bill establishes insurance exchanges through which eligible people without employer-based benefits can purchase subsidized coverage. However, the Senate Finance Committee recently rejected 2 Democratic amendments that would have created a public health insurance option to compete with private insurers,

Still, Meyers said Baucus’s bill contains a Consumer Operated and Oriented Plan (CO-OP) program to foster the creation of nonprofit, member-run health insurance companies that would be able to receive federal subsidies. “It sounds to me like kind of a public option,” Meyers said.

Direct/indirect benefits

Many provisions in both HR 3200 and the Senate Finance Committee’s bill directly and indirectly benefit psychiatrists and their patients, according to Meyers. Both packages, for example, bar discrimination based on health status and preexisting conditions and “that is huge,” he said. Both packages extend the current physician fee schedule mental health add-on as enacted in the Medicare Improvements for Patients and Providers Act of 2008.

Approaches to some controversial issues differed in the 2 bills. In his column in October’s Psychiatric News, APA president Alan Schatzberg, MD, described as “flawed” the sustainable growth rate (SGR) formula that Medicare uses to calculate physicians’ and others’ fees.2 Physicians and allied health care providers face a 21.5% Medicare payment cut on January 1, 2010, and further substantial cuts over the next several years.

APA distributed e-mail requests to its members asking them to communicate with their senators and representatives about Medicare’s SGR formula as it pertains to health care reform.

The House bill [HR 3200], according to Meyers, permanently fixes the SGR problem. Baucus’s bill, as it now stands, does not permanently replace the SGR formula but does postpone it for a year, “which has been pretty much how Congress has operated over the past 8 years or so.”

“The fact that the SGR [topic] is in both bills, albeit in different forms, indicates that Congress plans to do something with it,” he added.

Parity issues

Whatever happens with health care reform, Meyers said, APA’s “bench-line standard is to work to insure that we don’t undo or damage” the advances achieved through enactment of the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008. That act ensures that coverage of mental health treatment is on a par with coverage for other health conditions.

He explained that HR 3200 requires parity, the Senate HELP Committee’s bill requires a public plan to offer parity, and the Senate Finance Committee accepted an amendment to extend the parity requirement to all plans offered in the exchanges. These actions illustrate “how far the thinking has come on mental health issues,” Meyers said.

Other issues

Among other issues addressed in HR 3200, the Senate HELP Committee’s bill, and Baucus’s Finance Committee bill are preventive care, expansion of Medicaid, outcomes and treatment effectiveness research, and national strategies for recruiting, training, and retaining an adequate health care workforce. A comparison of key components of the 3 authorizing committees’ proposals for health care reform is available on the Henry J. Kaiser Family Foundation Web site http://www.kff.org/healthreform/sidebyside.cfm.



1. Rohack JJ. Statement of the American Medical Association to the Democratic Steering and Policy Committee, United States House of Representatives regarding the urgent need for enacting health system reform. September 15, 2009. http://www.ama-assn.org/ama/pub/health-system-reform/testimony.shtml. Accessed October 6, 2009.
2. Schatzberg AF. Board of trustees endorses HR 3200. Psychiatr News. October 2, 2009.

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