Time of Transitions

This final “Capitol Comments” article under my byline marks a number of significant transitions, both internal to APA and to our advocacy for psychiatry on Capitol Hill, in the executive branch, and in support of our district branches and state associations across the country.

Just a few weeks ago James Scully, M.D., became APA’s new medical director, and the Association moved its headquarters from downtown Washington, D.C., to Arlington, Va. Your APA staff did a magnificent job in making this a smooth move, and we are now busily sorting through myriad boxes and crates and getting situated in our new quarters. Your “Team DGR” was ready as the 108th Congress convened with single-party control of the House, Senate, and the White House. The Senate convened with a new majority leader, Sen. Bill Frist (R-Tenn.), who is a physician.

On a personal note, effective January 1, I stepped down as director of APA’s Division of Government Relations (DGR), although I am pleased to let you know that I will serve as a political/government relations/advocacy consultant to Dr. Scully and APA. For more than 20 years, it has been my great privilege to serve APA as the chief advocate for psychiatrists and their patients with Congress and the executive branch in Washington, D.C., and to assist you in your work on behalf of your patients and psychiatry at the state level.

Much has transpired in my 20 years at APA. Insurance coverage of mental illness has significantly improved. Thanks to your tireless advocacy, more than 30 states have enacted some form of nondiscriminatory health-insurance requirement. Working together, we have witnessed the federal maximum share of Medicare coverage of treatment of mental illness go from a nearly nonexistent $250 afterthought to a meaningful outpatient benefit. Congress enacted and the president signed a national nondiscriminatory coverage law requiring equality of lifetime and annual dollar limits between mental and other medical/surgical care. The national research budget devoted to biomedical and behavioral research on mental and addictive disorders has dramatically increased. Treatment options exist today that were not even dreamed of when I first joined APA. Psychiatry works in mainstream partnership with the AMA and all of medicine, with our patient advocacy groups, and, wherever possible, with other institutional and mental health groups.

What is most striking and personally gratifying is not the gradual easing of barriers to treatment, but the extraordinary degree to which the public and our political leaders have come to embrace our advocacy supporting the effectiveness of mental illness treatment and equal access to care as a matter of basic rights. When I started at APA, we were hard pressed to find any senators and representatives who would openly support our legislative agenda. Today, two-thirds of the Senate, well over half the House, and the president of the United States are on record as supporting a national law to end insurance discrimination against psychiatric patients. It is truly remarkable that the debate is no longer about “if” we should have such a law, but “when” and in what form. That is an extraordinary accomplishment and change in attitude.

Yes, there is much still to be done. Priority issues include the following:

• Parity: The devil will truly be in the details of any national parity law, and we still need to prod a reluctant few legislators into easing their opposition, which is based on stigma rooted in fear and ignorance. Their opposition is aided and abetted by powerful political forces opposed to any such law, mostly for business reasons.

• Medicare: Continuing gaps in Medicare coverage—such as the 50 percent copayment limit, the 190-day lifetime reserve, and the absence of a meaningful intermediate nonresidential benefit—must also be addressed.

• Psychiatric Workforce: We will need a sustained and focused effort to enhance the supply of psychiatrists nationwide, particularly those willing to serve in remote and underserved inner-city communities.

• Scope of Practice: We will be monumentally challenged by economically motivated nonphysician mental health practitioners who seek to obtain a “medical degree” by legislative fiat rather than medical education and supervised residency training and to expand their scope of practice at the risk of patient safety.

• Managed Care: We will need to provide support and leadership to individual members struggling with insurance plans whose main purpose is to deny medically necessary care rather than to ensure the provision of optimal biopsychosocial treatment.

• Research Funding: The era of easily achieved significant increases in federal research support for mental and addictive disorders is coming to an end. We face great challenges in sustaining the historic high levels of funding we have achieved over the past several years.

• Public Psychiatry: Above all else, we will need to work in partnership with federal and state legislators and patient advocates to craft an effective response to the crumbling public mental health infrastructure in an era of major national, state, and local budgetary shortfalls. These are very serious challenges for the next director of DGR and the new leadership of APA.

In closing, I would like to offer my deep appreciation, admiration, and gratitude to every member of the DGR staff. Their dedication to you, our members, and commitment to excellence have made Team DGR the medical association equivalent of Super Bowl and World Series champions. It is the nature of lobbying that many of our successes occur behind the scenes, out of public view. You should know how hard your dedicated and talented DGR staff has worked on your behalf throughout my tenure at APA. You will not find a better team in Washington, D.C.

Many of you know Gene Cassel, our longtime deputy director for regulatory affairs, who will now be acting director of DGR. Gene is well known to our elected leadership and has for many years provided strong staff support to our AMA delegation, as well as expert guidance on regulatory policy impacting psychiatry, and I wish him well. I am confident that with Nick Meyers, Michael Strazzella, Nancy Trenti, and Lizbet Boroughs continuing as your most able federal lobbyists, with dedicated support from Patti Moody; Paula Johnson, Heather Whyte, and Lisa Fields on crucial issues confronting our state associations and district branches; Jason Pray running our remarkably successful startup PAC operation; Julie Abadie coordinating our legislative and regulatory advocacy message; and Tom Graham, Emory Rogers, and Sara Makso providing truly dedicated support, your Team DGR will continue to ensure that psychiatrists are ably represented in Washington, D.C.

Special mention must also be made of the exceptional contributions of Linda Hughes, who for many years has done a great job keeping Team DGR running smoothly. She will now be running the APA Office of Ethics and District Branch/State Association Relations.

Finally, let me offer a heartfelt thanks to you and your dedicated and talented district branch/state association staff who have worked so hard on behalf of your profession and particularly your patients throughout my association with APA. The progress that we have made nationally simply could not have been accomplished without your tireless dedication and generosity.

This has been a remarkable journey together. My very best wishes to you and your families for a healthy, safe, and happy new year. I hope we will stay in touch in the months and years ahead. ▪