The Politics of Health Care Can the APA Make a Difference?

The bad news was delivered on the front page of The New York Times last December: The Mental Health Parity Act of 1996-the long sought after federal law that was supposed to discourage health benefits discrimination against the mentally ill-was described as having "failed" to achieve parity because insurers and employers take advantage of loopholes. Despite the critical nature of the report, however, no one from the American Psychiatric Association, not a single psychiatrist for that matter, is quoted in the article.

Although there may be numerous reasons why the story did not include a comment from the psychiatric profession, critics nevertheless point to the absence of an APA voice as symptomatic of a broader problem. With time running out on a host of issues critical to psychiatrists and the patients they treat, there is mounting concern that outmoded approaches to influencing Congress and public opinion mean the APA message won't have a strong political punch. While efforts are underway to meet the looming challenges, the question remains whether planned reforms could prove to be both too little and too late.

After years of debates over national health policy, it seems as if everything is suddenly coming to a head. For example, congressional activity directed at medical privacy-a hot-button issue for every segment of the health care system-is certain to crest during the next several months. Unless Congress enacts legislation by August, regulations promulgated by the Department of Health and Human Services will come into effect by default, a prospect feared by most psychiatrists who believe the rules won't adequately protect patients against wholesale disclosures of medical records. Meanwhile, there is mounting public support for legislative fixes to health care woes, including increased regulation of HMOs and insurers; enactment of a patient bill of rights; amendments to the Employee Retirement Income Security Act (ERISA) that would permit heightened oversight of health plans; and reassessments of laws affecting parity, health care reimbursements, research, physician work force issues and medical research.

For Steven Mirin, M.D., the APA's medical director, there is little question that the organization is up to the task. "One of the great strengths of the APA is the credibility of the Division of Government Relations with a substantial number of the members of Congress-both the House and the Senate," Mirin told Psychiatric Times. "Credibility is something that is built over a long period of time, in terms of relationships, of being able to deliver...information that turns out to be the correct information, and the ability to work with members of Congress and their staffs in drafting legislation, as well as simply responding to it."

Rodrigo A. Muoz, M.D., the asso-ciation's president, said, "We are about to announce the new APA, one that is member-oriented and devoted to activities that give priority to advocacy for our patients and for our members. The most important two activities that represent this advocacy are government relations and public affairs. In order to give more emphasis to these two functions, we will get them together under the same APA component to permit us to better interact with those who are likely to help us."

Currently underway is an internal restructuring that Muoz said will create "a seamless progression of actions from the members, to the district branches, to the assembly and to the board." The idea, ultimately, is to allow staff to rapidly mobilize APA members when it is time to move on legislative initiatives.

Grassroots Organizations

An initial effort to create that seamless progression stalled, pitting members keen on developing a grassroots infrastructure against an APA insistent on doing things its own way.

"Psychiatrists were telling us they wanted to know what to do and when to do it," said Deborah C. Peel, M.D., an Austin-based psychiatrist who will be the next president-elect of the Texas Society of Psychiatric Physicians. She is also a consultant to the APA's Joint Commission on Government Relations. "People are hungry for information about how to help our patients, when and how to intervene in the patient protection legislation process, and who to call. That is not coming out of the APA."

Initially encouraged by some APA officials to initiate a grassroots campaign, Richard S. Epstein, M.D., a Bethesda, Md., psychiatrist and an APA trustee-at-large, along with Peel and Ronnie S. Stangler, M.D., a Seattle psychiatrist, created an e-mail list that could immediately notify psychiatrists when it was time to turn up the political heat on both federal and state legislators. Epstein hoped that the network, with nearly 9,000 subscribers, would be "a powerful voice for our patients and profession."

But in the end, the APA told the group that it could not operate under the association's banner, even though the group promised to disseminate APA policies and positions on legislative issues. Although what became the Psychiatric Grassroots Network (PGN) still coordinates with the Division of Government Relations to come up with stands on health care issues, it is nevertheless a free-floating effort operating without the APA's imprimatur.In an interview with Psychiatric Times, Epstein lauded the efforts of the association's lobbying and public relations staffs. However, in order to fulfill a campaign promise to increase psychiatry's political influence, he ended up having to act on his own.

"I did this as a way of demonstrating that there are new ideas," Epstein said. "We need to advocate for our patients and our profession, and we need to be very vigorous about it by working together at a grassroots level."

Ronald A. Shellow, M.D., a Miami-based psychiatrist who has served as the APA's chair of the Joint Commission on Government Relations since 1993, however, said that the APA has been "exceedingly successful [in terms of government relations]," and vows to "continue [the activities] as well as we have been." Nevertheless, even he acknowledged that grassroots organizing requires more attention. "One of the problems, and this has been a problem all through medicine, has been that the profession is unable to mobilize physicians, including psychiatrists, to raise hell with their legislators."

Mirin acknowledged that the "whole issue of a grassroots network is absolutely crucial," adding that for any grassroots network to be useful to the APA, its district branches and its membership must represent a coordinated effort.

"State issues impact federal legislation. Federal legislation impacts the states. We can't have these two entities disconnected. So our goal is to build out a grassroots network that basically promulgates APA policy," he said.

In line with that goal, the APA has a public policy advocacy section on its Web site. It publishes newsletters and issue statements about federal, state and regulatory issues impacting psychiatry and health care. As part of that section, APA members can fill out a form to join the Division of Government Relations Grassroots Network. The network has a membership of 2,500 of the 40,000 APA members.

Learning From Others

Stangler, who is a consultant on the APA's Joint Commission on Public Affairs, points to the success of other groups in achieving the kinds of results she wishes psychiatrists could manage.

"Looking at the conservative wing of the Republican Party and their aggressiveness and tenacity in Clinton's impeachment matter, I think we have something to learn from some of their procedural and operating styles," Stangler said. "The tenacity and the focus are absolute requirements. We have to be everywhere, and we have to be everywhere all the time."

As an example, Stangler pointed to the National Alliance for the Mentally Ill (NAMI) and the way it has built a base of support in Congress over time.

"I look at a group like NAMI, that has really become a powerful force in public policy-making and this has to do with it being a group that has managed to coalesce disadvantaged and neglected people into a powerful force," Stangler said. "They are organized. They are omnipresent. They are clear about their agenda."

Meanwhile, their ability to affect public opinion also impresses Stangler. "When I read front-page stories in national newspapers about health policy, psychiatric, psychological or mental health issues, inevitably someone from NAMI is cited, quoted or consulted. While the public affairs arm of the APA is aspiring to have a far greater national presence, I think they recognize we've got a ways to go."

Whether the distance can be covered in the short time remaining before Congress takes up health policy reform measures is an open question for some, but not for the APA's Mirin, who said that the throes of internal restructuring shouldn't interfere with lobbying efforts. Once efforts to formalize the integration of certain government relations and public affairs functions are finally in place this spring, Mirin is confident the APA will be ready to take on Congress and public opinion.

"The APA needs to have its activities much more integrated than heretofore, because that's a much more effective way of doing business," he said. "We have lots of very talented people, but if they only function within their own silos, they won't be maximally effective. That's what I've been trying to accomplish here."

Mirin added that building a strong grassroots network is an important goal, but that it takes more than an e-mail listserve. "In any organization of 40,000 members, particularly when the specialty it represents is under siege, inevitably there will be people who feel the organization isn't moving fast enough to represent their interests," said Mirin. "Talk and e-mail messages are easy. Delivery of the passage of legislation; delivery of actual changes in federal legislation that have a direct impact on the reimbursements for psychiatric care; delivery on changes on how we view the confidentiality of medical records-that doesn't get done through a listserve. It gets done by nose-to-nose negotiations and activity at the state and federal level."

Jay Cutler, J.D., the APA director of government relations, agrees. The most effective strategy at this stage is to "continue to do what we have done in the past, while at the same time expanding our activities by having someone in-house assist us with media relations," he said, alluding to the coming integration of government relations and public affairs functions. But he conceded that, without proper teamwork, people could end up "stepping on each other's toes or forming a circle to shoot each other."

Nevertheless, achieving consensus over the coming months will remain an elusive goal. Unless APA insiders can harmonize divergent views on how to approach relations with legislators, some of the energy better directed at issues could be diverted to resolving internecine organizational battles. Ultimately, APA officers, staff and members will need to decide whether advocacy and lobbying efforts should continue to emanate from the top down, or shift to more closely embrace contributions from members outside Washington, D.C., in an expanded grassroots effort.

Mirin acknowledges that members should demand results that protect the profession of psychiatry and the patients it serves. "I'm not interested in rah, rah cheerleading," he said. "I'm interested in results-results for the patient and results for the profession."

Promising to streamline and enhance the APA's government relations and public affairs functions, while maintaining the ability to influence Congress, Mirin added, "I wouldn't have disrupted my entire life to come down here merely to be a cheerleader for psychiatry. The profession and its values and the welfare of patients are at stake here."