(From a long e-mail discussion thread. Some of the transitions of focus may be a little ragged-- but each point, I believe, is internally cohesive...)
FIRST-- My all time favorite graph that answers the question-- Why has health care become so expensive?--
AND NOW The Missive--
Let’s
address the idea of empowering ourselves—having agency for our profession and in
our professional life. The objections that have been expressed in this and
similar conversations are, in effect, that managed care profiteers and their
academic researcher servants have the pocketbook to have the ears of government
who set the regulations—our working conditions.
My major point is that I believe participating in the development of Improved
Medicare for ALL (IM4A) (aka Single Payer) gives us a greater voice to reach
those ears-- and to change which ears are important to begin with.
These problems
are not only well known but are highly motivating within the IM4A advocacy
community. However, that community is not yet well informed enough
about psychotherapy's apprehensions as a
result of our inaction which is in part because of continuing stigma and the "denial [and insufficient action or acceptance] on
the part of the psychoanalytic community about our increasing
marginalization." In the medical field "evidence
based" has more legs to stand on-- though there is also the alarms of the
"cookie-cutterization" of medicine.
The example I want to give of how IM4A advocacy
gives us a voice is about fee-for-service (ffs). It was clear during the
development of Obamacare ( even Clintoncare) that ffs was getting a bad rap and
being blamed as a major reason why our healthcare is so expensive. (Has
nothing do with insurance corporations’ putting profit over service and outrageous overhead designed to deny care, of
course.) Even last year during the debate around California's single-payer bill,
legislators, all so self-satisfyingly,
were attacking ffs as the demon. But the reality is that both the
current federal bills (Sanders
and Jayapal)
and the CA and NY (and probably others) call for two types of reimbursement--
Fee for service for individual and small practices and global budgeting for
institutions. While there is certainly much to explore-- especially how global
budgeting works out-- the point is it has been the IM4A movement that has
resurrected the efficacy of fee-for -service.
In the face
of all the managed care/political push towards the resource wasting, disparity
enhancing, clinically unsuitable beasts such as pay-for -performance, value-based and outcomes-based reimbursement, IM4A has actually put into legislative
language that fee-for-service is the preferred method of paying a
practitioner. Now that is power! Not, yet, of course,
enough to move from legislation to actualization-- but we are getting there.
Addressing the needs of this psychoanalytic community and mobilizing towards
IM4A is part of getting there.
If we take
it, the IM4A movement gives us the
opportunity to collectively work towards the clinical and administrative
structures that we know are right
for our profession and those we serve.
That’s my
narrative—And I’m sticking to it!
-------------
OK Folks! Thanks for getting this far. I am really delighted that this discussion of
ideas and apprehensions is taking off. Many substantial questions have been raised and it will take some length
to begin to attend to them. I hope to address a lot of your thoughts and
concerns. In so doing, I don’t want to come off as a know-it-all or dismissive
of people’s doubts. I hope the dialog continues into more comprehensive
discussions and options for engagement.
At the same time, as a result of decades of private and public
healthcare service and advocacy, I do have a lot of information and informed perspective
I would like to share with you. I surely
don’t have all the answers and want to continue to promote the questions.
(As I try to briefly address multiple
issues that have been expressed some of my comments will probably seem more “scatter-shot”
than others. As well, speaking to them
in this relatively brief time will lead to commentary that, invariably, will
need further exposition. A lot here for
those who plow their way through. But, if you want even more, see my WHY AND HOW SINGLE PAYER IS GOOD FOR THE
MENTAL HEALTH PROFESSION. )
To me, it is
axiomatic that our professional services—and all healthcare-- be available to
everyone. As you’ve probably heard“healthcare is a human right.” Following from that is that the profession
must be appealing enough to attract high quality people into it. I do not
believe it is self-serving at all to aspire and act towards sustaining ourselves
and our profession.
So much of
what has been talked about so far is the perfectly accurate and appropriate
criticisms about various aspects of the managed care-think control of our
profession. We express our distress about the development and misapplication of
“evidence-based” research; the disparagement of long-term/depth work, inadequate reimbursement; the minimization of
fee-for-service through the ever more prevalent so-called “value-based”,
outcomes based, pay-for-performance structures, reduced services, authorization
impasses and a host of other matters. Some of us (me, obviously, included) support
the idea of an influence base from which to address these. Actually, I would imagine that most of us
would like that. The question becomes
–What is/How do we create that base.
The
observation has been made and apprehensions expressed that our professional
organizations are far from adequate to take on this task. Worse, they are often collaborators in our
marginalization and subservience to “powers that be.”
To me, it is
essential to change things and move towards a more clinically suitable structure
for our profession, our work. The
Improved Medicare for All policy and advocacy efforts provide us with just such
an opportunity. (I know many have expressed disquiet not only around political
engagement but trepidation about and distrust for government involvement. Later in these comments I will address those—especially,
the latter.)
It has been
expressed that there is a negative impact of government regulations on rural
health and other minimization of services. To me, this is largely a result of
the control of those looking for profit to diminish care because it is not cost
effective . IM4A specifically calls for
regional planning based on need not revenue or profit and that resources will
follow the need.
One
example-- Due to data constraints (itself largely a result of the fractured
health systems and “proprietary” limitations)
it has been hard to evaluate the improvement of objective measures in health
as a result of Medicaid Expansion. But a recent study by the National Bureau of
Economic Research showed that the
Medicaid expansions substantially reduced mortality rates among near elderly
adults.
Relatedly, it
has been expressed that an over regulatory environment will favor bigness over
smallness. Of course, the goddess is in
the details but it is the desire to de-bureaucratize and re-relationalize
health care that is at the heart of the IM4A movement.
All Single
Payer proposals that I am aware of propose regional structures, including
clinicians, empowered to be involved in the political developmental
process-- and on-goingly in the regulatory and administrative structures
to develop and maintain systems to ascertain and address local needs—including
service level and reimbursement.
In this, and
all else about creating this system we most be ever vigilant and
participatory. The good news is that
participation is built into the system—if we take it. Is it easy ? Of course not.
That is why I have engaged in the effort to help create and define what Single
Payer will look like. There is a place for us and, thus far, we are
welcomed. I am on the Steering Committees of both the Bay Area and
California chapters of Physicians for a National Health Plan. How did I
get there?-- Some experiential and intellectual expertise, an activist
mindset and putting my ideas and self forward. It is, in particular, the
intellectual and idea arenas that I wish to hear from and share with
colleagues.
A major area
of discussion is the privileging of scientism and of medical and pharmaceutical
approaches to psychological health. This is where
our voice really needs to be heard.
A corollary to this is the service limitations
on the Master’s level licensure .
While, once more, the general thrust is towards democratizing health
care, these both, again, are matters where we need to continue to help inform
the process. Regarding who can deliver
services in the system—Sanders language seems to call for current Medicare eligible clinicians while Jayapal adds those eligible as state level Medicaid practitioners. In CA and other ( but not all) states that would
allow for all master level licenses. Another example where we have been heard
and influential but, also, of more work we need to do .
Further,
both California’s recent and New York’s still active Single Payer legislation set
up a structure in which individual and small practice clinicians will be able
to form into negotiating entities to collectively bargain for reimbursement and
administrative conditions. This aspect
is not in the current federal proposals.
But we can get it there !
WHO’S
COVERED-- Sanders' and Jayapal's proposals call for coverage for "residents".
It is not clear to me, but I am pretty sure, given the general level of
discussion in the M4A advocacy community, that is meant to refer to anyone who
resides in U.S.-- not only "legal" residents. Regardless,
both federal bills go on to say that their intent is that "every person in
the United States has access to health care." Certainly, CA's and
NY's proposed legislation are clear that they intend to cover all who reside in
state.
OTHER SYSTEMS--UK
is a system in which government through taxation pays for health services and
employs the people who work in the system--
clinicians, administrators--much like our VA system. In Canada—Only MD’s are covered in mental
health. That’s been true since their
Medicare/Single Payer was initiated. There
is private insurance that covers therapist services with other licenses.
Frankly,
though I have expended some effort in trying to get a better understanding of
mental health and substance abuse services in Canada and other countries, much
of those structures are not clear to me. Kathy Moore has unearthed some stuff I
am eager to hear about as well as read them and more. Any others that have understanding of how
other MH systems work-- please share!
Our current Medicare
through taxation and premiums pays for services delivered either in public or
private settings. The abolition of
premiums/deductibles/co-pays, etc. to be replaced by progressive taxes is one
of the Improvements of Improved Medicare for All. (And most people will pay
less in taxes than they do now for health coverage and services.) There will be a wider range of
services-- including dental and vision than the current Medicare.
(Elizabeth Warren has just released her plan for paying for IM4A and it does not propose raising middle class taxes. It is a large document with, I am sure, plenty of nits to pick. But it is showing that we are capable of making this happen!)
Another part
of the Improvement is that IM4A will pay completely for services. There will be no holes drilled into the
system by corporate push for profit and adverse risk reduction. Because I pay
for the best Medigap from a private insurer I have had two very expensive
surgeries-- gall bladder and back-- and have paid nothing! $0.00 !
for those surgeries and all
related treatment (as well as other minor medical issues). But why do we have to pay a private
corporation when we could just as easily and more cheaply pay/add the “supplemental” to regular
Medicare. IM4A will not need to be
“supplemented”.
ROLL OUT
PROBLEMS-- Of course there will be. But it’s
been done—Canada
rolled out its system over 40 some years of development in an environment with
little or no insurance corporations. Taiwain
after two years of legislative process made
its transition in less than a year in 1995.
And we did Medicare in less than a year, 1965—on punch cards! The current Senate bill calls for a four
year transition and the House has a 2 year
roll out. Incrementalism—like a public option—that leaves insurance
corporations in command and does not capture the tremendous administrative cost
savings will only delay the development of a true single payer system.
GOVERNMENT
CAN/CAN’T DO IT
Big Pharma
and the Insurance Industrial Complex are the rulers of the system because of
their clout to dominate governing and regulatory policy We need the countervailing power of grassroots
and organized effort channeled through
government process.
The corporate bureaucracy is far
more insulated than the governmental. Yes, ever since Reagan and before
there has been a concerted neo-liberal
effort-- with too much "New Democrat" collusion-- to demonize
government. I am a Roosevelt (Warren Sanders) Democrat-- that
believes we can get government to serve the people and that we have more access
to it than we will ever have to corporate board rooms. We can design a system that will take professional clinical concerns
into consideration at least in balance with-- if not more influential than administrative
demands. So, one effect of political effort is to revitalize
the belief and demonstrate that government can do good .
Profit
creates relational distance. In fact, I believe that the massive
corporate profits require the hiring and escalation of sociopaths that can
exercise the profit imperative over the social. And large non-profits (e.g.
Kaiser) are just as driven by "surplus" rather than
"profit". ($2 billion or so a year, over $20 billion
accumulated ) There is no profit in government insurance services.
It may be
hard to believe/remember but during the mid-20th
Century (and the Progressive movement of the early 20th) there was a
sense of turning to the government to protect the populace (99%) and a can-do
trust/using of the government (of, by and)
for the people. Not ignoring continuing inequities and
discrimination, the incremental improvement, socially and fiscally, made
that period the most economically equal in the history of the world. (AND--It activated the 1%-- memorialized in a blueprint
for opposition in the 1971 Powell memo.) The struggle for single payer and its attendant
rehabilitation of a positive belief in government is part of a cultural shift
back towards a “we” society rather than
a divisive “me” society. This, in itself, is socially and
psychologically healing and helps create a supportive culture.
We work
building grassroot pressure and advocacy so as to influence government to “do
the right thing”. Those “wins” through government engagement continue to be battled
by corporatism—e.g. mental health parity
that the insurance corporations fight tooth and nail and still violate. (thank
you, Meiram Bendat for your related court victories!)
Much,
granted--far from all, of admin structures imposed by government are a result
of the influence of the corporate mind set and the intentional effort to favor
the private over the public. There is no reason other than subservience
to corporate masters to need either supplemental Medicare or Medicare Advantage.
The "advantage" to Medicare Advantage is to the insurance
corporations. (Advantage-- but not, yet, game/set and match.)
They are overly subsidized, are able to select healthier/cheaper patients,
create narrow somewhat phantom networks (especially in mental health) and have
the muscle to resist fraud
investigations.
Research and
development-- The federal government’s share of research and
development reduced from 70% in 1960’s and 70’s to just less than 50% in 2017. Yet Science Magazine
reports that while “multiple mechanisms
interact and contribute to the trend, federal research increasingly appears to
fuel the innovation that ultimately leads to jobs, industrial competitiveness,
and entrepreneurial success.”
Bloomberg has
called the NIH the backbone of the research ecosystem. And the Center
for Integration of Science and Industry--In
a snapshot review points out that all new drugs that were approved for market from 2010-2016 came out of research funded by NIH. This includes, for example, the Hep C
treatment that costs $100 to manufacture,
bought by Gilead and marketed at $80-100,000.
Renown
economist, Dean Baker, of the Center for Economic Policy and Research has said
that government marketing of pharmaceuticals would prove safer and reduce costs
up to 80%.
We have all
been fed and/or fighting the propaganda that government is the problem. It is taken as near gospel that we, as a people, can’t do better through
government where appropriate for social needs than the private sector--corporations.
Not unlike healthcare this is also expressed regarding public support for education. Again, far from perfect, and worse from
purposeful strangulation, but we sure are a lot better off than without it.
Imagine the impact on society and the economy if we hadn’t developed such
supports as land grant colleges, a strong public education system, the GI Bill
and, until the last 40 years or so, access to relatively inexpensive higher
education. Perhaps not a lot of imagination is needed—All we need do is look at
the current state of student debt as public moneys for higher education has
been more and more withdrawn and education for profit has gained more and more
ground. There are a lot of parallels in
the position of the education profession and the mental health profession. Not the least of which is that as each profession
includes more and more women—the powers that be feel more and more need and
opportunity to control it and gain profit from it.
As I learned
long ago as part of the alternative /underground press and getting each edition
of the newspaper on the huge presses through several adjustments to align
everything just right on each page-- Life is a series of successive
approximations. The movement towards achieving
the human right of health care--
including mental health – grows incrementally. But it can’t be achieved as
long as we are separated from health care delivery and service by the profit motive.
When Single Payer —or whatever lesser
next steps along the way are achieved, if we are not involved the same old
scientism will dominate.
In its storm metaphors and awe-full imagery of
Jacob wrestling with an Angel many have read a sense of submissive surrender to
spirit in Rilke’s poem, The Man Watching. I see, also, exhortation to continuing and growing
despite the awesome forces facing us along the way …
Winning
does not tempt that person.
This is how we grow: by being defeated, decisively,
by constantly greater beings.
This is how we grow: by being defeated, decisively,
by constantly greater beings.
(altered to a
pan-gender version)
I invite you
to join this encounter with the constantly greater beings…
Stephen
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