With the enactment of President Obama's landmark health care reform legislation, the Patient Protection and Affordable Care Act [P.L. 111-148] (ACA), and its subsequent affirmation by the U.S. Supreme Court, psychology is entering into an unprecedented era as a health care profession. The underlying statute proffers broad federal objectives, delegating to the states the authority to develop the specifics for implementation in order to effectively address local concerns and priorities. Eventually, all Americans will have access to patient-centered primary care. Change is always unsettling and unquestionably the "devil is in the details."
The Alliance for Health Reform has been holding a series of informational briefings on Capitol Hill, recently focusing upon Medicaid Expansion. Pursuant to the Court's decision, the individual states must now decide whether to participate or "opt out" of the Medicaid expansion provision of the law. Currently, 12 states have decided to participate, 7 states have decided to "opt out," and the remaining states have yet to announce their participation status. Unlike professional nursing which has obtained mandatory coverage of nurse-midwives, certified pediatric nurse practitioners, and certified family nurse practitioners (whether or not the practitioner is under the supervision of, or associated with, a physician or other health care provider), organized psychology has been notably lax in seeking Medicaid recognition. Our practitioners are covered under its very broad provider language.
The Alliance notes that Medicaid is the largest public health insurance program in the nation, covering over 60 million low-income individuals, or roughly 1 in every 5 Americans. The program is administered by the states within broad federal rules and financed jointly by the states and the federal government. Medicaid beneficiaries include children and some parents, people with disabilities, and seniors. Without Medicaid, most of its beneficiaries would lack coverage for care they need. It provides essential funding to safety-net providers, including hospitals and health centers serving the underserved. It is the single largest source of coverage for nursing home and community-based long-term care. Altogether it finances 17% of all personal health spending. Under ACA, Medicaid eligibility will expand in 2014 to reach millions more poor Americans – mostly uninsured adults. The program will become the coverage pathway for most low-income individuals and the foundation of the broader public-private system of health coverage envisioned by ACA. In 2009, Medicaid covered 31 million children, 16 million nonelderly adults, 6 million seniors, and 9.5 million persons with disabilities (including 4 million children). Almost all elderly Medicaid enrollees and 39% of disabled Medicaid enrollees are also covered by Medicare (comprising 9.4 million "dual-eligibles").
A New England Perspective: This Fall Bob McGrath, director of the Fairleigh Dickinson clinical psychopharmacology and integrated care programs, addressed the Vermont Psychological Association. "VPA was particularly fortunate to also hear from Anya Rader Wallack, chair of the Green Mountain Care Board, which is the organization responsible for implementing health care reform in Vermont. All of the speakers during this visionary conference highlighted the importance of collaborating with those implementing health care reform to make sure psychology's voice is ultimately heard.
"At times the anxiety was palpable, as the participants struggled with the uncertainty and risks that are inherent to change of this magnitude. As the day progressed, I identified several underlying themes to keep in mind when discussing the challenges of health care reform: 1. Psychologists have reason to be concerned that the ACA institutionalizes systems in which a conflict of interest can potentially exist where health care providers benefit from restricting care. We have to remember that the current system, in which health care providers benefit from offering unnecessary care, threatens to bankrupt the nation without achieving better outcomes. We must work to ensure that an emphasis on quality of care balances cost containment concerns. 2. Psychologists have reason to be concerned about quality metrics, because we're living in a period where oversight is being used by insurers to ration care arbitrarily. We have to remember that the intended purpose of the new metrics is to provide that balance between cost containment and quality of care at the level of the population. We must work to ensure that those metrics are used for their intended purpose rather than to justify eliminating services for the individual. 3. Psychologists have reason to be concerned about pressure to offer brief, time-limited, population-based interventions. We have to remember that the current system is incapable of meeting the mental health needs of the general population. We must work to ensure that the entire spectrum of services remains available including long-term individual psychotherapy. And, 4. This is going to happen whether we like it or not. We have no choice but to deal with it. We ask our patients to act despite their anxiety all the time. We have to do the same."
The Hawaii Perspective: Coral Andrews, executive director of the Hawaii Health Connector: "You often speak candidly about the expanded role of advanced practice staff in the 'new' delivery system. I serve as the Regent for the American College of Healthcare Executives (ACHE) Hawaii-Pacific Region. The national organization and the Chapter are focused on Diversity at all levels of the health care industry. It's our flagship issue. Diversity at all levels: ethnicity, gender, equal access to leadership positions, respecting diverse points of view, etc. More information about this initiative can be found atwww.ache.org. As the health care industry evolves into new business models, new professional structures and new models of care, so too will the strategy by which we attract and retain talent. I am already seeing it as we work to establish the health insurance exchange. Our workforce is blended and pulls from multi-industry markets, not just health. As a result, we have to be competitive with these other industries as well.
"Nurses, psychologists, social workers, etc. are coming into their own with the ACA. The shapes and sizes of talent won't be the traditional ones that we've long since expected. Professionals, within and outside of health care, will emerge in leadership positions to support the requirements needed to fully implement ACA. As a result, a new market will emerge. Our leaders will need to diversify their thinking and align their strategies differently to insure that they attract and retain talent.
"At the Connector, we are getting ready to go through a process with the help of Integrated Healthcare Strategies, a national human capital strategy firm, to help us benchmark our positions in this emerging market and to assist our Board with access to information that helps to clarify/contrast pre-ACA ideology with post-ACA realities. Diversity in the talent, diversity in the approach to human resources, and diversity in the workforce are all things that will need to evolve alongside the more visible challenges that we are seeing in the models and systems of care. I look forward to supporting ACHE's efforts to advancing Diversity at all levels of the health care industry." Aloha,
Pat DeLeon, former APA President – HPA – December, 2012
