As our nation experiences the steady implementation of President Obama's landmark health care reform legislation, thePatient Protection and Affordable Care Act (PPACA), over the next five to ten years, it is important to appreciate that the bill was crafted primarily with consumers (i.e., patients) in mind and not clinicians. Perhaps as legislative modifications are made, based upon practical experiences, we will eventually see the enactment of the Single Payer System which the liberals so vocally championed. There are a multitude of questions to be answered. For example, how will the provision which requires health insurance plans to utilize at least 80% to 85% of the premium dollars collected to pay medical bills or otherwise improve their customers' health, ultimately be interpreted? Will this allow insurance companies to pay clinicians for upgrading their office computers or attending continuing education (CE) courses? The nonpartisan Congressional Budget Office (CBO) estimates that PPACA will reduce the federal deficit by $143 billion over the first ten years of enactment, ensure that 94% of Americans have health insurance, and effectively bend the ever-escalating cost curve. Does this suggest that with 76% of Medicare spending currently being for patients with five or more chronic diseases, that we will see a special, national focus upon this growing population? It is simply too early to predict with any sense of certainty. Change is always unsettling and takes time, especially when important.
It is useful to view the enactment of PPACA within its historical context. On May 22, 1964 President Lyndon Johnson laid out his vision for a Great Society at a Universityof Michigan commencement, which at that time was the most attended non-football event in campus history. "I have come today from the turmoil of your Capitol to the tranquility of your campus to speak about the future of your country. The purpose of protecting the life of our Nation and preserving the liberty of our citizens is to pursue the happiness of our people. Our success in that pursuit is the test of our success as a Nation. For a century we labored to settle and to subdue a continent. For half a century we called upon unbounded invention and untiring industry to create an order of plenty for all of our people. The challenge of the next half century is whether we have the wisdom to use that wealth to enrich and elevate our national life, and to advance the quality of our American civilization.… Will you join in the battle to build the Great Society, to prove that our material progress is only the foundation on which we build a richer life of mind and spirit? There are those timid souls who say this battle cannot be won; that we are condemned to a soulless wealth. I do not agree. We have the power to shape the civilization that we want. But we need your will, your labor, your hearts, if we are to build that kind of society. Those who came to this land sought to build more than just a new country. They sought a new world." On July 30, 1965 the President signed P.L. 89-97, the Social Security Amendments of 1965, and thus made Medicare [and Medicaid] the law of the land.
During his address before his first Joint Session of Congress, President Obama held out a similar vision and challenge. "We will rebuild, we will recover, and the United States of America will emerge stronger than ever…. The costs of health care eats up more and more of our savings each year, yet we keep delaying reform…. Now is the time to jumpstart job creation, re-start lending, and invest in areas like energy, health care, and education that will grow our economy, even as we make hard choices to bring our deficits down.… (T)his is America. We don't do what's easy. We do what is necessary to move this country forward…. (W)e can no longer afford to put health care reform on hold…. I suffer no illusions that this will be an easy process. It will be hard. But I also know that nearly a century after Teddy Roosevelt first called for reform, the cost of health care has weighed down our economy and the conscience of our Nation long enough. So let there be no doubt: health care reform cannot wait, it must not wait, and it will not wait another year." Compelling visions provide the context within which day-by-day experiences shape specific implementation strategies.
Six months after enactment of PPACA, the Chairmen of the two Senate Committees which were most involved in crafting the legislation stated: Finance -- "Americans have reason to celebrate. The new law put Americaon the road to a more sustainable consumer-friendly health care system. The new law putAmerica on the road to a healthcare system in which all Americans have access to quality, affordable health insurance. And the new law put America on the road to a health care system in which patients and their doctors – not insurance companies – control patient care. These transformative changes will not happen overnight…. Today, with this 6-month mark, we pass a key milestone on our road to providing quality, affordable health care to all Americans. This milestone is justone of many along the road. But this milestone is one that signals an end to the insurance companies' worst abuses."
Health, Education, Labor, and Pensions (HELP) -- "On September 23, the law's six-month anniversary, six major reforms kicked in. Now the law: * Bans insurance companies from dropping patients' coverage…. * Bans denial of coverage for children with pre-existing conditions…. * Cracks down on benefit payment limits. Insurance companies are prohibited from imposing lifetime dollar limits on essential benefits…. * Provides for appeal of insurance company decisions…. * Guarantees free preventive care…. * Extends coverage for young adults. Young adults are now allowed to stay on the parents' plan until 26…. [And, mental health parity is finally the law of the land.] As many predicted, the law is increasingly popular as Americans get better acquainted with its broad range of benefits and consumer protections…. Mark my words: Americans will not allow their hard-earned benefits and protections to be taken away. We will stay the course, defending the strong reforms in this new law and creating a reformed insurance and health care system that works not just for the healthy and the wealthy but for all Americans." President Obama's vision will ultimately curtail the ever-escalating costs of health care; enhance the availability of high quality Primary Care; make Wellness and Preventive Care a national priority, as well as eliminating racial and geographical Health Disparities; and empower Educated Consumers to take responsibility fortheir health care, utilizing the most up-to-date advances in the communications and technology fields (i.e., Health Information Technology, Telehealth, and the utilization of data-based Gold Standards of care). The next decade will be very "interesting," for consumers and practitioners alike – truly uncharted waters.
The health care environment of the 21st century in which psychology will practice will be increasingly interdisciplinary in nature. California nurse-psychologist Ann Carson, reflecting upon the Nurse Managed Health Clinic provision in PPACA: "This is an amazing document and gives me hope for the future of nursing and health care. In many ways, a return to the earlier practice of nursing within the public health realm would be a huge step forward. I was taught prevention (primary prevention) in my nursing program in the late 1960s. The rest of the health care world, especially medicine, seems a bit delayed in recognizing the value."
In December, 2009 President Obama issued a Memorandum for the Secretary of Health and Human Services, calling for a Medicare demonstration to test Medical Homes in federally qualified health centers. "My Administration is committed to building a high-quality, efficient health care system and improving access to health care for all Americans. Health centers are a vital part of the health care delivery system. For more than 40 years, health centers have served populations with limited access to health care, treating all patients regardless of ability to pay…. There are over 1,100 health centers across the country, delivering care at over 7,500 sites. These centers served more than 17 million patients in 2008 and are estimated to serve more than 20 million in 2010…. Health centers use interdisciplinary teams to treat the 'whole patient' and focus on chronic disease management to reduce the use of costlier providers of care, such as emergency rooms and hospitals. Federally qualified health centers provide an excellent environment to demonstrate the further improvements to health care that may be offered by the medical homes approach. In general, this approach emphasizes the patient's relationship with a primary care provider who coordinates the patient's care and serves as the patient's principal point of contact for care…. (They) also emphasize activities related to quality improvement… and coordination…. Therefore, I direct you to implement a Medicare Federally Qualified Health Center Advanced Primary Care Practice demonstration."
We fully expect that those colleagues who possess psychopharmacological skills will be at a distinct advantage in the ever-evolving healthcare system. Accordingly, we were pleased to learn from Steve Tulkin that this September, the Postdoctoral Master of Science Program in Clinical Psychopharmacology at the California School of Professional Psychology at Alliant International Universitybegan its fourth National Cohort with close to 60 students. Students attend classes live over the Internet, and can ask questions and participate in class discussions utilizing this technology. Psychologists in 23 states (fromHawaii to New York) are participating in the class, and one psychologist is participating live from South Africa. He spoke briefly during the first meeting of the class to thank his U.S. colleagues, and express his hope thatSouth Africa will enact prescriptive authority legislation in the next couple of years. Aloha,
Pat DeLeon, former APA President – National Register – October, 2010
