Single Payer and Public Behavioral Health

(Though this was originally published in 2006 and a few stats are out of date-- they are worse now-- I have been asked to "repost" this. One clarification may be important, the reference to "President-elect Santos" -- As was somewhat popularly known at the time, he was TV's "West Wing" young Democratic presidential candidate with an ethnic name who won the election against an elderly white republican senator from the southwest. Yeah, like that could ever really happen. Let me know your thoughts. )

We are coming to a tipping point in health insurance coverage in this country. I believe it is and should be towards universal, single payer healthcare/insurance. The question relevant here is how does public behavioral health impact what is to come. While many of us, understandably, are enshrouded in the fog of our current inefficient system, there seems little discussion of how to influence the development of structure, policy and delivery systems of behavioral healthcare in a national healthcare program.

It seems important to muster here some of the arguments and realities of this coming tipping point. Perhaps we need say no more than it is costing General Motors close to $2000 per car manufactured to pay for the health insurance of its current and past employees. This is a competitive burden for all our major employers that their foreign competitors do not have to carry. Why? Because every other “developed” country has some form of national healthcare that spreads the cost – and, not incidentally, improves the outcomes. ( The U.S. generally ranks around 25th in national healthcare outcomes.)

The administrative/non-treatment costs in utilizing private insurance ranges from 15 to 30%. Our national single payer healthcare for seniors ( MediCare) has a 3% admin rate. (As “President-elect Santos”, Senator Kennedy and Congressman Conyers and many others have been saying—we could just drop the “over-65” part of the MediCare legislation.)

Then there is that the U.S. has a consistently growing percentage of “permanently” uninsured—currently 46 million--16% of the population, with an additional 16 million underinsured.

Oh, and, by the way, between government programs and public employment, government is already paying over 60% of insurance costs.

A single payer system is estimated to save over $200 billion annually, cover everyone and improve outcomes.

The current system gives undue policy influence to private insurers and the pharmacy industry.

Rationing ? Bureaucratic control ? Yeah, right, like we don’t have that now—and it will improve under single payer.

Imagine, if you will, a society in which each of us knows that we, our families, our neighbors are free from the stress of healthcare worries and the possible financial destruction a medical crisis can portend.

And while there is so much more weighing in this balance toward a tipping point perhaps the biggest practical point is that --GM is spending nearly $2000 per car.

So what is happening out there that we need to be part of ?

Well, first of all let me speak to some pseudo-reforms. Space does not permit discussion of some of the finer points of (not-even) halfway measures—such as Massachusetts and Vermont, “consumer-directed”, health savings accounts, “Clintoncare”, etc. Suffice it to say that they all rely on and keep in place the current inefficient multiple insurance system.

What is important is that action is moving towards true single payer. My own state, California, has a bill moving through its legislature. It faces the usual resistance and suffers from state level incrementalism. But it may yet serve as a model for national healthcare.

Congressman Conyers and the Congressional Healthcare Caucus have introduced a National Health Insurance Act-HR 676. This bill is going in the right direction and needs the support of the field, consumers and practitioners. Two major national groups are supporting this process—as well as other activities. Healthcare Now (www.healthcare-now.org) is establishing “citizen hearings” through out the country as well as other actions. Physicians for a National Health Program (www.pnhp.org) have been supporting, developing proposals and making the arguments for single payer since at least 1989

Both these organizations and others have extensive websites. Yet, it is difficult to see how behavioral healthcare will be addressed/provided in these models. There are many questions that come to my mind—and that we need to be involved in to influence. Just a few-- Will services be on demand or will they need prior authorizations? Are we looking at a return to fee-for –service? Will the program essentially be a “ticket” for service ? Will there be ways to aggregate funds into programming ? Will the regulations and billing processes be as onerous as they currently are for MediCare Mental Health? Will it be allowed to truly be a “behavioral health” approach and dispense with substance abuse morality issues? Will it help promote service delivery to lower socio-economic groups and efforts against stigma? How will it impact us as employers, providers? Theory is payroll tax and employee tax will be likely revenue sources— how will these be structured so that they are more affordable than the current system ?

It won’t come for free—but it will be less expensive and provide better care. How its finances and delivery systems are structured will be best determined by those involved in its creation and maintenance. These issues need to be being addressed in all our policy and advocacy discussions.

So while you/we are dealing with the usual cascade of crisis that seem to make up our work life, we really need to attend to this point before we are tipped without being part of the tipping.

In what has become pretty much a “tag line” for PNHP—“Of all the forms of inequality, injustice in health care is the most shocking and inhumane—Dr. Martin Luther King, Jr.

Stephen Adair Vernon, LMFT; July 12, 2006 Improved MediCare For All!