Following the Money into Our Mental Health Care Systems


Imagine a psychiatric utopia… What does it look like?

money trail



Most of the examples of social psychiatric complacency concerns from last Friday’s column result in an increase of mental health problems. Yet, our national system of health care—if it can even be called a system—has problematic obstacles to mental health care, ranging from inadequate resources to the business control resulting in epidemic rates of physician burnout. At one point, perhaps over 10 to 35 years ago, there were loud and clear calls for a single payer system in the United States, as we are the only “western” country without one, but by now that has dissipated. So-called Obamacare gave us a taste, but its advances continue to be at political risk.

However, Physicians for a National Health Plan (PNHP) has not given up, as I was reminded by getting their newsletter recently. When it began 35 years ago, I was one of several psychiatrists who addressed the benefits of PNHP for psychiatry. Now, I am reminded of what we are missing by a prominent Canadian psychiatrist, who wrote me:

“Imagine a system where:

A. You never have to consider anyone’s ability to pay.

B. You get generally 100% reimbursement of billings, and the rate is the same whether your patient is a millionaire or 3rd generation welfare recipient.

C. About 1% of your professional time is spent on billing.

D. No one is telling you how long you can keep someone in the hospital or how long or how frequently you can treat someone as an outpatient.”

Of course, there are admitted problems in Canada, including easy enough access and how to monitor quality of care, but to me it has always sounded like a psychiatric utopia compared to the fragmented systems of the United States.

PNHP advocates for a single-payer movement. The closest we have now is Medicare, but by now business has also entered that in the option of Medicare Advantage Plans or, as some call them, Medicare Disadvantage! Medicaid is what covers the financially disadvantaged in the United States, but the major private company providing Medicaid managed care, Centene, just reached settlements with 14 states for allegations of overcharging state Medicaid programs for drugs, to the tune of over $800 million. As I discussed way back in 1997 in my book on the ethics of managed care, profits have been high for the for-profit businesses and their leaders, taking much money out of the patient care dollars.1 Given that my medical school did have a capitation contract with Centene at one time, I saw those significant profits firsthand. As another saying goes: “who has the gold makes the rules.”

Time to snap out of our complacency for a revival of concern for a single payer system that would provide psychiatric coverage akin to Canada, is it not?

Dr Moffic is an award-winning psychiatrist who has specialized in the cultural and ethical aspects of psychiatry. A prolific writer and speaker, he received the one-time designation of Hero of Public Psychiatry from the Assembly of the American Psychiatric Association in 2002. He is an advocate for mental health issues related to climate instability, burnout, Islamophobia, and anti-Semitism for a better world. He serves on the Editorial Board of Psychiatric Times™.


1. Moffic HS. The Ethical Way: Challenges and Solutions for Managed Behavioral Healthcare. Jossey-Bass; 1997.

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