In our judgment, the 2010 enactment of President Obama's landmark Patient Protection and Affordable Care Act (ACA) (P.L. 111-148) reflects our nation's commitment to finally ensuring that all Americans will have timely access to "gold standard" health care when required. The underlying statute has been crafted to provide for incremental implementation with many of the major provisions taking effect by 2014 and still others by 2019-20. The individual states have been provided with considerable flexibility to shape broad federal mandates in a manner that best reflects local priorities and concerns. Complex and highly controversial, in upholding the constitutionality of the law the Chief Justice of the U.S. Supreme Court opined: "We do not consider whether the Act embodies sound policies. That judgment is entrusted to the Nation's elected leaders. We ask only whether Congress has the power under the Constitution to enact the challenged provisions." Justices Ginsburg and Sotomayor provided a different perspective: "The provision of health care is today a concern of national dimension, just as the provision of old-age and survivors' benefits was in the 1930's…. In enacting [ACA] Congress comprehensively reformed the national market for health-care products and services…. Unlike the market for almost any other product or service, the market for medical care is one in which all individuals inevitably participate…. Not all U.S. residents, however, have health insurance. In 2009, approximately 50 million people were uninsured, either by choice or, more likely, because they could not afford private insurance and did not qualify for government aid."
In developing ACA's underlying regulatory schema, Congress passed several bills, including the American Recovery and Reinvestment Act of 2009 (the Economic Stimulus legislation) which provided significant funding (estimated at $19+ billion) and comprehensive programmatic authority for aggressively moving our nation's health care system into the 21st century world of communications technology (i.e., virtual realities, electronic health records (EHRs), telehealth, and cross-patient and cross-diagnostic comparisons (competitive effectiveness research)). Partisan politics precluded the usual process of technical modifications and as a result, it is difficult to accurately predict ACA's specific impact upon the daily practices of our colleagues. Without question, however, the health care world of tomorrow will be fundamentally different than our practitioners and educators ever imagined. Health care will be patient-centered, integrated, and interdisciplinary in nature. Reimbursement priorities will shift from curative, procedure-driven acute illness care to holistic, wellness-oriented, primary and preventive care. Mental health services will be deemed "primary health care" services; no longer to be considered "specialty care" except under special conditions. As the Institute of Medicine (IOM) has repeatedly noted there is an "inextricable link between mental health and primary care…. Primary care providers address a broad range of health issues to which mental health concerns are integral. Mental, behavioral, and physical health are so closely entwined that they must be considered in conjunction with one another." From a policy frame of reference, the critical importance of the psychosocial-economic-cultural gradient of care will be increasingly recognized. In many ways psychology, nursing, and the behavioral sciences will have an unprecedented opportunity to shape the future of their professions and our nation. These will be exciting times, with unique opportunities and challenges.
I recently had the opportunity to visit the joint clinical-community doctoral psychology program at the University ofAlaska, including flying out to an Indian Health Service (Alaskan Native) clinic in ruralBethel. Students and faculty at the Anchorageand Fairbanks campuses interact seamlessly utilizing modern day video technology. Courses taught on either campus, including faculty and/or student meetings, are fully interactive. It was, for example, admittedly a bit startling to have participants introduce themselves along one side of the table, continue into the virtual space, and then cycle back to where I was sitting. Treatment staff at the Bethel clinic report being readily able to utilize in real-time the medication expertise of psychiatrists located in Washington State andMinnesota, who over time have become intimately familiar with their patients, again in a seamless fashion. From a policy frame of reference, distance learning, telehealth services, simulation labs, health information technology (HIT), and utilization of interactive electronic health records (EHRs) are inseparable – they represent the exciting infusion of communications technology into the health care environment. Interestingly, at the time ACA was enacted the Administration estimated that only 5% of physicians possessed fully functional electronic health records. Their goal was to bring this up to 90% by 2019.
Although electronic devices are pervasive throughout our culture, they are a relatively new phenomenon in the health care world. The Alliance for Health Reform notes that the Economic Stimulus legislation included a provision, the Health Information Technology for Economic and Clinical Health (HITECH) Act, which has already jump started the process, focusing upon "meaningful use." Health care transformation has begun, with HHS announcing that providers' adoption of HIT has doubled in two years. Nevertheless, special challenges exist for solo and small practices. Coordination of care, active patient involvement, and the development of a relevant workforce continue to be high priorities for the Administration. Under HITECH $677 million has already been allocated to support a nationwide system of Regional Exchange Centers to make sure that primary care providers receive the help they need. Change is definitely coming. The American Association of Colleges of Nursing 2012 Fall Semiannual meeting is entitled "Taking Advantage of Technology in Nursing Higher Education." What are we as psychologists doing to address the critical issue of licensure mobility? Why is a senior colleague who was licensed in Alaska, a former State Association President, not able to continue providing clinical services in ruralNew York during her retirement? The underlying policy rationale for licensure is patient protection. Are the residents of these two states so qualitatively different? Accordingly, I commend the National Register for its visionary efforts to effectively address this increasingly important issue as the advent of technology and NHI steadily overcomes traditional geographical barriers.
"Seems you are giving voice to the experiences of colleagues who are retiring from the field. I was in Denver a few weeks ago and attended a CE session on psychiatric disorders in the aging population. Among other things, I took note of the observation by the presenter that oftentimes depression occurs in successful CEO types who retire because no one listens to them anymore because they no longer have any authority. Hard to imagine this happening with the psychologists we know since I am sure most of them have lots of things they want to do when they retire. I sure did. Off to see daughter and husband inVermont with train rides down to NYC, NJ, and PA to see friends" [Jon Esty]. Aloha,
Pat DeLeon, former APA President – National Register – October, 2012
