Feature

“A great step forward.”

That’s how APA President Carol D. Goodheart, EdD, describes the historic health-care reform legislation that President Barack Obama signed into law in March.

The law — the Patient Protection and Affordable Care Act — will extend health coverage to 32 million previously uninsured Americans. That new coverage will come mainly from an expansion of Medicaid, increased federal support for the Children’s Health Insurance Program and the creation of state health insurance “exchanges” that offer health plans to individuals and small businesses.

The law will enhance consumer protection by ending discriminatory practices by health insurers, such as establishing annual or lifetime limits, excluding people with pre-existing conditions and arbitrarily canceling coverage.

The law also furthers APA and APA Practice Organization (APAPO) priorities for health-care reform, including integrating psychologists into interdisciplinary health-care teams, ensuring access to mental and behavioral health care and emphasizing prevention.

And what’s good for the public is good for psychologists, says Goodheart. “There’s going to be increased demand for mental health services under the new law,” she says.

However, APA, APAPO and psychologists must continue their advocacy efforts to fulfill the promise of this ground-breaking legislation.

Progress on priorities

To make sure that the health-care reform legislation addressed psychology’s needs, APA launched an association-wide advocacy effort a year ago, with support from members. Members of APA’s Div. 38 (Health), for instance, provided research findings that helped the government relations staff of APA and APAPO make the case for psychology’s role in the prevention and treatment of physical disorders. Hundreds of APA members also visited Capitol Hill and contacted their elected representatives to push for psychology-friendly language.

Those efforts paid off, says Norman B. Anderson, PhD, APA’s CEO.

“What’s really exciting is that attention to APA’s top priorities for health-care reform can be found throughout the 1,000-plus pages of legislation,” he says.

Senior government relations staff point to several highlights:

  • Fostering integrated health care. One of the major accomplishments of the law is that it recognizes the critical role of mental and behavioral health in overall health, says Ellen Garrison, PhD, APA’s senior policy advisor. The law acknowledges psychologists’ role in treating patients with mental health problems, those with physical health problems and those with both. For example, the law authorizes grants to establish community-based, interdisciplinary health-care teams that would serve as patients’ “health homes.” The legislation also authorizes grants to set up demonstration projects that would integrate primary-care and specialty-care services for special populations, such as individuals who have both mental illness and chronic disease.

    Katherine C. Nordal, PhD, APA’s executive director for professional practice, pointed to the role that advocacy played in achieving this goal. During APAPO’s State Leadership Conference in March, says Nordal, psychologists emphasized the importance of integration during visits to more than 300 congressional offices.

    Enhancing prevention and wellness. The law devotes a great deal of attention to prevention, says Diane L. Elmore, PhD, acting associate executive director for APA’s Public Interest Government Relations Office.

    It establishes a fund for expanded and sustained national investment in prevention and public health programs. It also authorizes grants to establish national centers of excellence for depression; calls for funding for research, educational programs and services related to postpartum depression; and establishes programs for comprehensive prevention, detection and treatment of elder abuse, neglect and exploitation.

    In addition, the law authorizes the creation of two prevention task forces, one to review evidence about clinical preventive services and another to do the same with community-based preventive interventions. The clinical preventive services task force is required to review recommendations from scientific societies, such as APA. That task force is especially important, says Elmore, because its findings will be used to determine what preventive services are reimbursed.

    Expanding psychology’s work force. The law authorizes training grants to accredited master’s, doctoral, internship and postdoctoral psychology programs, with a set-aside of at least $10 million for doctoral, internship and postdoctoral training. “This was a challenging and successful effort by APA to extend our Graduate Psychology Education program,” says Nina Levitt, EdD, associate executive director for APA’s Education Government Relations Office. “The potential here is to more than triple the current size of that program, which would be a major accomplishment.” This interdisciplinary training initiative focuses primarily on meeting the needs of underserved rural and urban populations, as well as children, older adults, victims of abuse and trauma and racial and ethnic minorities.

    In addition, the law expands eligibility for several new and existing geriatric education and training programs to psychologists, as well as to psychology programs and students. It also authorizes a loan repayment program for psychologists and other qualified health professionals who provide mental and behavioral health services to children and adolescents.

  • Improving access to mental and behavioral health care. APA and APAPO worked to ensure that access to mental and behavioral health care, as well as substance abuse care, was part of the essential benefit package that will be offered to enrollees in the new health-care exchange plans.

    The law also prohibits discrimination based on health status, which will keep group health plans and health insurance issuers from denying coverage because of mental or physical illness, medical history, past claims, genetic information or similar factors, says Garrison.

    The health-care reform law builds on previous successes, adds Marilyn Richmond, JD, assistant executive director for government relations at APAPO. “The legislation includes the parity provisions for which we fought so long and achieved with the Mental Health Parity and Addiction Equity Act,” she says. Passed in 2008, that law forbids group health plans from placing more restrictive financial and treatment limitations on mental health and substance use services than on medical and surgical benefits.

    The new health-care reform law also preserves Medicare payments for psychologists. As part of a routine five-year review in 2007, the Centers for Medicare and Medicaid Services made steep cuts in Medicare reimbursement levels for psychotherapy and other psychological services in order to offset increases in payments for evaluation and management services. In 2008, APAPO persuaded Congress to substantially restore payments for psychotherapy — the only codes that received legislative relief — but that restoration expired at the end of 2009. Thanks to many months of advocacy by grassroots psychologists and APAPO, says Nordal, the health-care reform law extends the 5 percent Medicare psychotherapy payment restoration through the end of 2010, retroactive to Jan. 1 of this year. It is estimated that psychologists will receive some $20 million from the measure, which will help ensure patients’ access to their services, says Nordal.

  • Eliminating health disparities. To help identify and thus reduce disparities, the law requires federally conducted or supported health-care and public-health programs to collect and report comprehensive data on race, ethnicity, sex, primary language and disability status. The law also authorizes the creation of offices of women’s health within several federal agencies and reauthorizes the Indian Health Care Improvement Act, including the American Indians Into Psychology program. In addition, it establishes grants for developing, evaluating and disseminating cultural competency research, demonstration projects and model curricula for health professions schools and continuing education programs. “This law reflects the tireless leadership of APA, alongside hundreds of organizational partners, to ensure that our nation recognizes and addresses health disparities as a significant public health concern,” says Elmore.

  • Supporting psychological research. The law authorizes the creation of a private, nonprofit organization called the Patient-Centered Outcomes Research Institute, which will synthesize and conduct research comparing the clinical effectiveness of different treatments. “We recently sent a letter to the acting comptroller of the U.S. Government Accountability Office to make the case for a psychologist to be included on the institute’s board of governors,” says Geoff Mumford, PhD, associate executive director for APA’s Science Government Relations Office. “It is important that psychology have a voice on matters related to the development of the institute’s priorities and initiatives.”

  • Collaborating with consumers and caregivers. The law establishes a new national insurance program to help adults with functional disabilities maintain their independence while alleviating the burden of family caregivers. The law also requires the national network of Geriatric Education Centers to offer free or low-cost training to family caregivers and direct care providers.

Next steps

While getting the new law passed is a major achievement, says Garrison, it’s only the first step. Now the focus must shift to how the law gets implemented.

For one, the government must figure out how to put the law’s provisions — such as the state health insurance pools — into practice.

“There’s a lot of work to be done to establish the federal and state infrastructure to be able to deliver these services,” says Garrison. “We will likely be involved in this effort.”

That implementation work will be happening in the face of continued public debate over key aspects of the legislation, especially its requirement that individuals buy health insurance, says Garrison.

In addition, APA and other advocates must work to ensure that the initiatives the law authorizes receive the appropriations they need to come to fruition.

“The onus is on APA and other organizations to continue to make the case to Congress about how critical these initiatives are,” says Garrison. “It’s up to us to secure federal funding for these newly authorized grant programs, including those related to integrated care and psychology workforce development.”

For more about how the health-care reform law affects practicing psychologists and consumers of psychological services, go to APA's Practice Central.

For more information, visit APA’s health-care reform website.


Rebecca A. Clay is a writer in Washington, D.C.