APA at Work for You on Capitol Hill

In the last several of these columns, I told you about some of the ways in which APA pursues one of its primary missions: advocating for the interests of our patients and our profession. As you now know, when legal cases of importance to the field arise, we participate as a party and as amicus in the courts, and we support our district branches and state associations in their advocacy efforts before state legislatures, regulatory agencies, and the courts as well. This time, I’d like to tell you something about our efforts in Congress and the federal regulatory agencies, the critical work carried out by our Division of Government Relations (DGR).

Perhaps the best way to convey to you the work of DGR is to describe my experiences over the last several years with regard to a single issue of great importance to our field—the privacy of our patients’ medical records. Beginning in the mid-1990s, a series of bills were introduced in each session of Congress proposing national regulation of medical privacy. Unfortunately, few of these bills were concerned with “privacy” in the usual sense of the term; most were aimed at facilitating access to patients’ records by a variety of interests, from insurance companies to law-enforcement authorities. Their implications for psychiatry—where privacy is a pillar of our work with patients—were dire.

DGR staff monitored this legislation as it was being formulated, analyzing the provisions of each voluminous bill. They contacted other medical and advocacy organizations to mobilize their concern about the privacy-threatening provisions and conveyed those concerns to members of Congress and congressional staff. As each bill came up for a hearing, DGR made sure that APA was invited to testify, positioning us as medicine’s major advocate for patient privacy. Richard Harding, M.D., our immediate past president, and I shared the task of presenting our case to Congress, between us probably appearing at close to a dozen hearings over the years. Each time, DGR helped us prepare our testimony and briefed us on the members of each panel and their particular concerns. The effect of this activity was to make clear to Congress that psychiatry and medicine as a whole would not sign off on legislation that materially impaired patient privacy.

Though congressional efforts to develop legislation continued, by the late 1990s the action shifted to the executive branch. The federal Department of Health and Human Services (HHS) was charged with writing a report making recommendations on medical privacy, and if Congress failed to pass a bill by a fixed deadline, to write binding federal regulations on its own. DGR staff met repeatedly with staff at HHS, before and after the report appeared, to argue psychiatry’s case for protecting patient privacy. They arranged for Dr. Harding and me, and other APA leaders, to meet with HHS Secretary Shalala and her staff, and with the lead HHS and White House staff persons dealing with privacy and health in the Clinton and Bush administrations. Each time a new draft of the regulations appeared, in consultation with APA leaders, DGR prepared extensive analyses and critiques of its provisions.

As every psychiatrist knows by now, the final HIPAA medical privacy regulations, which go into effect in mid-April, are far from perfect. But they do contain special protections for a class of psychotherapy notes and a provision limiting disclosure in most cases to the minimum necessary to accomplish the purpose at hand. Perhaps most important, the regulations do not override more protective state privacy laws—all provisions that APA fought for in Congress, with HHS, and in contact with the White House. The end result is flawed, to be sure, but our patients would be faced with a worse situation had it not been for the determined efforts of DGR.

To get a sense of the scope of the efforts of the 15 staff members of DGR, take this account of their extensive work on medical privacy and multiply it several-fold. They track a large array of issues at the federal level, including Medicare and Medicaid rules and funding; patients’ rights legislation; parity in insurance coverage for psychiatric disorders; issues affecting the Veterans Affairs system; funding for NIMH, SAMHSA, and other federal agencies dealing with research on and services for mental illness; and children’s issues such as TV violence, juvenile justice, and psychopharmacologic treatment of childhood disorders. And this is just a small fraction of the issues with which DGR is involved. Indeed, whenever a member of Congress expresses a concern that may impact psychiatry, or a regulatory agency explores rules that could affect our field, DGR is ready to respond. And when the APA Board identifies priority advocacy areas, DGR proactively makes our case.

So far, I’ve focused on DGR activities at the federal level, which is where the bulk of the division’s efforts are targeted. But several DGR staff work exclusively on state-level issues. They track bills and regulations dealing with parity, scope of practice, mental health law, managed care, and the like, providing support to APA district branches and state associations in their advocacy efforts. A state legislative field representative from DGR travels the country to train APA members and district branch staff in responding to issues arising in their states. DGR also provides staff support to a number of APA components, APAPAC, and APA’s AMA delegation, and for activities such as Mental Illness Awareness Week and the Academic Consortium, the latter a group that advocates for increased funding for psychiatric research and training. They are also our liaisons to other advocacy organizations, many of them members of the Mental Health Liaison Group, for which APA provides considerable leadership.

For many years, DGR was led by Jay Cutler, J.D., one of the best-known and best-liked lobbyists on Capitol Hill. Jay stepped down from that role at the end of 2002, having earned the gratitude of every psychiatrist. Currently, Gene Cassel, deputy director for regulatory affairs and deputy special counsel, is serving as interim director as a search process for a new head is under way.

It is neither easy nor inexpensive to maintain psychiatry’s presence in the halls of Congress and the offices of the federal agencies. But I truly believe that this is one of the most important things that APA does for America’s psychiatrists and their patients—and one of the best reasons to be an APA member. ▪