BIOL PSYCHIATRY 1990;27:123-124
123
EDITORIAL
A National Health Program for the USA
According to the most recent 1982 APA survey (1987, based on 1982 data), the most recent awxilab~e, there are, about. 32,000 practicing psychiatrists in the USA, who tend to congr~~gate in cities, with rural areas underserved. In our state hosl~itals it is not uncommon to tind a ~ingle psychiatrist serving several hundred patients. For most ps3,~i~iatrists, private practice is the main source of income, with fees varying ~nywhere from "$20 to $150 or more a visit. About half of these visits are for p~ychotherapy and in 1982 the average cost of a psychotherapeutic session ",as $70, with a standard deviation of $15. Only a quarter of these private psychiatric patients are fully covered by insurance, another qu-~ter pay entirely themselves, and about half pay 50% of the costs. A typical American psychiatrist may spend 50 hours a week in his work, and will see 35 to 40 patients in that tirae. Service coverage of our population is vet3' unevenly distributed. As Hollingshead and Redlich (1958), showed years ago, our middle class patients are more likely to be getting psychotherapy for their neuroses, while poor people get somatic treatment for their psychoses. Though psychiatry is by no means the most remunerative specialty, physicians on the whole earn relatively good incomes and mos~ would not like to see the preser~t individualized system of service changed. The USA and South A~rica are the only tw,3 industrialized nations without a national health plan, and voices are being increasingly raised for a more rational system of health services for our population. Mounting costs on the one hand and the extraordinary strains now imposed by tht. AIDS victims (to say nothing of the burgeoning dangers of Lyme disease, drug addiction, and venereal diseases) are, making these demands more urgent and there is now a real possibility of change. Physicians For A National Health Program is a rapidly growing organization with increasing influence. According to a recent Harris/Harvard poll, 89% of Americans think the US health system needs fundamental change and 61% would like something like Canada's national health insurance system. No plan can possibly satisfy all interested sections or evade the risks of abuse and corruption, but if one agrees that the public interest is paramount, some proposals can be offered as a tentative starting point. It should be acknowledged at the outset that it is not health services, important as they are, but rather the overall standard of livhtg that is the key factor in maintaining levels of health flor the public. Furthermore, the biggest return for public investment in health will come not from treatment but from prevention. At the present time, of all money spent by the government on health services, only 2.9% goes into preventive public health activities: this should be at least doubled. Several states, notably Massachusetts and Washington, have initiated local legislation to ensure medical coverage for all, mainly by requiring health insurance for the employed ~'ld offe~'ing analogous public assistance for t~e unemployed, but the plans are far from adequate. The American Public Health Association is pushing a program for early enactment by Congress of a comprehensive national health plan. In the near future, Rep© 1990 Society of Biological Psychiatry
0006-3223/90/$03.50
124
BIOL PSYCHIATRY 199o;27:123- ! 24
Editorial
resentative Hem y A. Waxman (D-CA), chairman of the Subcommittee on ~-~ealth and the Environment, will be introducing a Sense of Congress resolution under the title "Health Care for All," which will reflect the policy goals of the APHA for national health care in the USA. According to information provided by the APHA we now spend I I. 1% of our gross national product, or $500 billion a yearma per capita expenditure of $1,926 for health care, higher by far than any other nation but with services and health statistics inferior to many. A third of our population has no health insurance at all, and the remainder only incomplete coverage. Our local facilities for the medically needy are collapsing under the burdens of demand. The impending resolution for Congress will demand universal medical coverage and ~omprehensive preventive and rehabilitative services without income limits, responsive and accountablc public systems to achieve this aim, fair payment to providers, adequate training for all professionals, and widespread public education. A more detailed prospectus put forth by the National Association for Public Health Policy under Dr. Milton Ten'is, a Past-President of the APHA, calls ~pecifically for the inclusion of dental, psychiatric, :~nd long-term ca~e; elimination of all geographic and fina~cial baniers; no direct paym~ilt to individuals; and encouragement of group practice, as technology has outrun solo medicine. Budgets of provider organizations shall be subject to public scrutiny, with reasonable regulation of profit and adequate consumer participation at all level~. Local state autonomy would ensure adaptation to local needs, quality control, and personnel standards and make provision for continuous analysis, change, compliance, and detection of abuses. It is proposed that the federal government provide the bulk of the necessary funds, with supplementation by the states based on ability to pay. The system would be supported by general taxation, by individual health insurance payments, and by special taxes on alcohol, tobacco, noxious foods, firearms, and toxic substances in industry: these special taxes would thus at the same time serve to protect and to support public health. This complete package will reduce overall health costs for the public while greatly improving services, including psychiatry. It is interesting to anticipate how such a plan might influence the direction of psychiatry: it would be reasonable to expect a ~;reater commitment of medically trained psychiatrists to treatment of psychoses. Research support as presently constituted need not be disturbed by any such reorganization, and might weii expand as urgent health needs become apparent under the system. Research priorities would then be more likely to t~e aetermined by such needs rather than by profitability. There will no doubt be formidable opposition to propositions such as these, but one may hope that the public interest will prevail.
Joseph Wortis References Hollingshead AB, Redlich FC (1958): Social Class and Mental Illness. New York: John Wiley and Sons. Koran LM (ed) (1987): The Nation's Psychiatrists. Washington, DC: American Psychiatric Association.
123
EDITORIAL
A National Health Program for the USA
According to the most recent 1982 APA survey (1987, based on 1982 data), the most recent awxilab~e, there are, about. 32,000 practicing psychiatrists in the USA, who tend to congr~~gate in cities, with rural areas underserved. In our state hosl~itals it is not uncommon to tind a ~ingle psychiatrist serving several hundred patients. For most ps3,~i~iatrists, private practice is the main source of income, with fees varying ~nywhere from "$20 to $150 or more a visit. About half of these visits are for p~ychotherapy and in 1982 the average cost of a psychotherapeutic session ",as $70, with a standard deviation of $15. Only a quarter of these private psychiatric patients are fully covered by insurance, another qu-~ter pay entirely themselves, and about half pay 50% of the costs. A typical American psychiatrist may spend 50 hours a week in his work, and will see 35 to 40 patients in that tirae. Service coverage of our population is vet3' unevenly distributed. As Hollingshead and Redlich (1958), showed years ago, our middle class patients are more likely to be getting psychotherapy for their neuroses, while poor people get somatic treatment for their psychoses. Though psychiatry is by no means the most remunerative specialty, physicians on the whole earn relatively good incomes and mos~ would not like to see the preser~t individualized system of service changed. The USA and South A~rica are the only tw,3 industrialized nations without a national health plan, and voices are being increasingly raised for a more rational system of health services for our population. Mounting costs on the one hand and the extraordinary strains now imposed by tht. AIDS victims (to say nothing of the burgeoning dangers of Lyme disease, drug addiction, and venereal diseases) are, making these demands more urgent and there is now a real possibility of change. Physicians For A National Health Program is a rapidly growing organization with increasing influence. According to a recent Harris/Harvard poll, 89% of Americans think the US health system needs fundamental change and 61% would like something like Canada's national health insurance system. No plan can possibly satisfy all interested sections or evade the risks of abuse and corruption, but if one agrees that the public interest is paramount, some proposals can be offered as a tentative starting point. It should be acknowledged at the outset that it is not health services, important as they are, but rather the overall standard of livhtg that is the key factor in maintaining levels of health flor the public. Furthermore, the biggest return for public investment in health will come not from treatment but from prevention. At the present time, of all money spent by the government on health services, only 2.9% goes into preventive public health activities: this should be at least doubled. Several states, notably Massachusetts and Washington, have initiated local legislation to ensure medical coverage for all, mainly by requiring health insurance for the employed ~'ld offe~'ing analogous public assistance for t~e unemployed, but the plans are far from adequate. The American Public Health Association is pushing a program for early enactment by Congress of a comprehensive national health plan. In the near future, Rep© 1990 Society of Biological Psychiatry
0006-3223/90/$03.50
124
BIOL PSYCHIATRY 199o;27:123- ! 24
Editorial
resentative Hem y A. Waxman (D-CA), chairman of the Subcommittee on ~-~ealth and the Environment, will be introducing a Sense of Congress resolution under the title "Health Care for All," which will reflect the policy goals of the APHA for national health care in the USA. According to information provided by the APHA we now spend I I. 1% of our gross national product, or $500 billion a yearma per capita expenditure of $1,926 for health care, higher by far than any other nation but with services and health statistics inferior to many. A third of our population has no health insurance at all, and the remainder only incomplete coverage. Our local facilities for the medically needy are collapsing under the burdens of demand. The impending resolution for Congress will demand universal medical coverage and ~omprehensive preventive and rehabilitative services without income limits, responsive and accountablc public systems to achieve this aim, fair payment to providers, adequate training for all professionals, and widespread public education. A more detailed prospectus put forth by the National Association for Public Health Policy under Dr. Milton Ten'is, a Past-President of the APHA, calls ~pecifically for the inclusion of dental, psychiatric, :~nd long-term ca~e; elimination of all geographic and fina~cial baniers; no direct paym~ilt to individuals; and encouragement of group practice, as technology has outrun solo medicine. Budgets of provider organizations shall be subject to public scrutiny, with reasonable regulation of profit and adequate consumer participation at all level~. Local state autonomy would ensure adaptation to local needs, quality control, and personnel standards and make provision for continuous analysis, change, compliance, and detection of abuses. It is proposed that the federal government provide the bulk of the necessary funds, with supplementation by the states based on ability to pay. The system would be supported by general taxation, by individual health insurance payments, and by special taxes on alcohol, tobacco, noxious foods, firearms, and toxic substances in industry: these special taxes would thus at the same time serve to protect and to support public health. This complete package will reduce overall health costs for the public while greatly improving services, including psychiatry. It is interesting to anticipate how such a plan might influence the direction of psychiatry: it would be reasonable to expect a ~;reater commitment of medically trained psychiatrists to treatment of psychoses. Research support as presently constituted need not be disturbed by any such reorganization, and might weii expand as urgent health needs become apparent under the system. Research priorities would then be more likely to t~e aetermined by such needs rather than by profitability. There will no doubt be formidable opposition to propositions such as these, but one may hope that the public interest will prevail.
Joseph Wortis References Hollingshead AB, Redlich FC (1958): Social Class and Mental Illness. New York: John Wiley and Sons. Koran LM (ed) (1987): The Nation's Psychiatrists. Washington, DC: American Psychiatric Association.
