APA President Urges Support For Single-Payer Insurance System

Psychiatrists need to “tirelessly advocate” for a single-payer, universal health care system so every American has access to care as a right, not a privilege.

That was the message that outgoing APA President Steven Sharfstein, M.D., delivered to those attending the Opening Session of APA's 2006 annual meeting last month in Toronto.

“To advocate and to lead, we must say five simple words about the state of our health care system in the U.S. today: the emperor has no clothes,” said Sharfstein, president and CEO of the Sheppard Pratt Health System in Maryland.

Sharfstein reminded his audience that in the speech he had delivered at last year's Opening Session, he challenged fellow APA members to become involved in advocating for patients and the profession of psychiatry at the local, state, and national levels.

His challenge did not end with his presidency, however. “We cannot slow down,” he said. “Advocacy is not just calling on others to do what we want; it is a shining light for others to follow.”

Sharfstein's year as president was punctuated by more crises and high-profile news events than usual. His term got off to a running start when he found himself being interviewed by Katie Couric on the “Today” show in response to antipsychiatry remarks that Tom Cruise had made to Matt Lauer a few days earlier. The incident had a silver lining: “At the end of it all, I can only thank Mr. Cruise for giving psychiatrists across North America the opportunity to get our message out—that we are physicians who prescribe treatments that work.”

But the incident also raised an issue that Sharfstein had addressed in his speech last year as well. He noted that one weapon the antipsychiatry movement uses against American psychiatry is its relationship with the pharmaceutical industry. While the industry has developed drugs that have transformed the lives of countless psychiatric patients, he said, it abides by ethics and values that are different from psychiatry's, and psychiatrists need to be mindful of that difference.

“Our advocacy in favor of access to effective pharmacopeia should never have been seen as mere marketing on behalf of industry; it must come from a dispassionate reading of the science, access to all clinical trial data, and our clinical experience,” he said.

To ensure the credibility of continuing medical education (CME), Sharfstein called for independent review of CME programs and the phase-out of educational events sponsored by a single drug company. Also, he reminded his audience that accepting gifts from drug company reps generates distrust in patients.

Psychiatrists must be vigilant over other core values of the profession as well, he said. After reading in the New England Journal of Medicine that psychiatrists were participating in the interrogation of detainees at the U.S. Naval Station at Guantanamo Bay, Sharfstein expressed his concern in a letter to the assistant secretary for health in the Department of Defense. That letter led to an invitation to tour Guantanamo with the top health leaders in the military and other leaders of medical and psychological organizations. They were briefed on the involvement of “behavioral science consultation teams” and were told that while stress techniques had been used in the past, current techniques focused on building rapport with detainees because the development of positive relationships was found to be more effective. That wasn't an acceptable alternative for Sharfstein, however.

“It is the thinnest of thin lines that separate such consultation from involvement in facilitating deception and cruel and degrading treatment,” he said. The detainees, being held as enemy combatants with no legal rights, live in despair, and multiple suicide attempts and hunger strikes are common. “Our profession is lost if we play any role in inflicting these wounds.”

Psychologists have taken a position allowing them to provide consultations in interrogations, Sharfstein noted, “and if you ever wondered what makes us different from psychologists, here it is.” Earlier that day, he announced, the Assembly, and then the Board of Trustees, voted in favor of a position statement reconfirming that psychiatrists should not participate in prisoner interrogations (see page 1).

Two other major events during Sharfstein's presidential year demonstrated the Bush administration's failure to take care of the poor and disadvantaged in this country, he said. The first was Hurricane Katrina late last summer, and the second was the launching of the Medicare Part D prescription drug benefit on January 1.

Regarding Katrina, he praised the many APA members who helped traumatized survivors—some of whom were survivors themselves—but expressed outrage over the government's failure to follow through on promises to provide health care and other assistance to them. Many survivors were poor and had lost everything to the violence of the storm and flooding.

Four months later, APA had a front-row seat for the train wreck that occurred when Medicare Part D went into effect. APA and other advocacy groups had warned the government about the serious flaws and limitations of Part D, Sharfstein said, but these warnings went largely unheeded. In particular, APA and its partners were concerned about the 6.5 million patients dually eligible for both Medicaid and Medicare; beginning January 1, their drug coverage was moved from Medicaid to Medicare. Within days of the new year, reports proliferated about patients who could not get the medications they needed for a variety of reasons, from confusion over which plan they had been enrolled in to high copays they could not afford, he noted.

The program's unreasonably complex design and rocky start, said Sharfstein, represented “another abandonment of the most poor and vulnerable of our patients, another shocking insight into the failure to care for the less fortunate.”

The federal government needs to address Part D's many inadequacies, but more than modest tinkering is required, said Sharfstein. “The solution is for the federal government to establish a basic drug plan that works for those who fail in the private Part D plans,” he advised. “This is a concept so obvious that it is easy to be pessimistic that it will ever be adopted.”

The events that Sharfstein weathered this past year underscored the importance of the advocacy mission in which he had challenged his fellow APA members to join him. He left them with this simple but weighty message:

“We must tirelessly advocate for [single-payer universal health reform]. As the health care crisis extends and mushrooms, with more and more Americans without adequate coverage, the opportunity for such change will come at national, state, and local levels. And we must be there as advocates for our patients.” ▪