Editorial

Abstract

Reform of our health care system, for years an emotionally charged issue among the general public, has now been assigned priority status by the current administration in Washington. This past year, the President assembled a task force consisting of the best and brightest. Individuals representing diverse interests within the complex and fragmented universe of medical services were consulted, including consumers, patients with pre-existing medical conditions, physicians, insurance companies, pharmaceutical companies, small and large business employers, nurses, and hospital administrators.This massive and unprecedented review of the national health care system culminated in a presidential proposal for reform. The proposal has several main features, the most noteworthy of which are: (1) Universal Eligibility and Coverage. The proposed plan strives to guarantee coverage to all citizens from cradle to grave. Coverage would not be limited by employment status, health status or age. Articulating a goal of universal coverage represents a dramatic change from our current system in which an estimated 37 million Americans have no coverage and an estimated 60 million Americans are underinsured. (2) Freedom of Choice. One of the proposal's goals is that Americans would maintain the right to personally select a physician. (3) Increased Financing Base. The proposal advocates financial contributions from several sources, including employers, employees, and those outside of the work force; (4) Cost Containment. In particular, the proposal aims to eliminate bureaucratic waste. (5) Extensive Coverage. The proposal seeks to extend benefits to previously noninsured and underinsured areas of medicine. Specifically, in a praiseworthy reversal from our current system, mental health service has been included as a component of primary health care.When I heard the details of this health care plan initially, I had two reactions--one optimistic and one slightly more pessimistic. My optimism derived from the fact that mental health services were being included in the category of primary health care. For so many years psychiatry has been considered a step-sibling to other medical specialties. As a poor relation to some of the more prominent medical disciplines, psychiatric services were often cut or completely eliminated from an individual's primary care. Even when psychiatric services were included, coverage tended to be limited to pharmacotherapy rather than psychotherapy. Indeed, in many health care plans psychotherapy was not considered a medical service. However, inclusion of general mental health care in the proposal suggests the experts have come to acknowledge that psychiatric illnesses are as genuine and serious as organic illnesses and that flexible treatment plans should be provided.My overall response, then, was favorable and I was heartened by this proposal. Nonetheless, several features of the plan raised my concern. For example, would it be possible to pay for such a system so that everyone truly benefited? Moreover, what are the basic mental health benefits covered? The plan allows that limited mental health benefits would include a maximum of 30 days per episode of inpatient care and a 60-day annual maximum, increasing to 30-days by the end of the decade. Outpatient visits would be limited to 30 per year, and cost sharing would be eliminated by the end of the decade. Medical management, evaluation and assessment, and substance abuse counseling would not be limited.As practitioners we can certainly applaud the basics of these provisions. However, several criticisms must be raised. Most of us know all too well that emotional disturbances do not adhere to a rigid time clock. In particular, psychotherapeutic treatment, which is contingent on the patient's unique emotional disclosures, is difficult to relegate to a circumscribed period of time. If a doctor told a patient with cancer that the condition could only be treated for 60 days or a patient with a heart condition that therapy would be limited to a three-month period, most of us would protest, arguing that it is absurd to limit medical treatment in advance without being able to assess the individual progress of the patient. …