Is Health Care Reform Going to Fail Again?

I've been watching the debate over health care reform and I'm losing hope that it will happen. People of good will can disagree about the best way to deliver health care to all Americans. But, we're not seeing that. Instead, the debate is about nonsense. Things like:

• You're going to substitute socialized medicine for my Medicare! (No, Medicare IS socialized medicine and nobody is trying to mess with it.)

• You're going to make health care elitist, so only the wealthy will have good health care! (No, the way it is now, only the better off can get good health care. Obama wants to make it less elitist.)

• The government will withhold health care and let old people die! (No, nobody has proposed that and nobody would tolerate that.)

• An anonymous bureaucrat will control my health care! (What do you think is happening now? With public health care, you can write to your congressman. Under the current system, you get to write to the company that denied you coverage.)

• It's going to be too expensive! (No, doing nothing is too expensive. Nobody has argued with President Obama's point at his last press conference, that doing nothing will double our health care costs in ten years, while further reducing the number of people covered.)

• I won't have the freedom to choose my health plan! (You don't have that freedom now. Your employer selects the plans you get to choose from. If you're lucky, the plan you can afford is adequate. If we have a "public option," that plan will be available to everybody, actually increasing choice.)

• I won't have the freedom to choose my doctor! (The way it is now, you have to choose a doctor who takes your plan. If your employer decides to change your plan, you might have to change doctors. That won't change unless regulations require insurance companies to accept all willing providers. Fat chance.)

• I won't be able to keep my current plan! (Yes, you will. There is nothing in any of the current proposals to keep you from doing that.)

• I'll be forced to buy insurance when I don't want it. I should have the right to go without insurance! (No, we're all in this together. You never know when you'll fall down the steps, get bitten by a mosquito carrying Lyme disease, or be diagnosed with cancer. Just like with car insurance, you pay into the system so you can get the benefits when you need them.)
  

The health insurance companies like the system the way it is. They're making money hand over fist. They don't want any changes and they are throwing money at both parties (1.4 million dollars a day!) to defeat reform.
Worse yet, the Republican Party has decided that defeating Obama is more important than helping US citizens. They have been actively feeding this nonsense through their usual media outlets. They ought to be ashamed of their lies, but I don't think they have the moral fiber.
There is no reason we should be holding to the current system. It's a social and economic mess. People are going bankrupt with medical bills, while others have no coverage at all and only get treatment at an emergency room when they are really sick. Furthermore, we cannot compete internationally if we continue to throw good money after bad for health care.
Every other western nation has managed to provide health care for all its people. Why can't we? There's only one reason we can't: We've got Republicans and they don't.
Blue Dog Democrats are bad enough, but at least they're willing to vote for something. If health care reform fails it will be on the Republicans, and they will happily take the credit. But, while they are celebrating, they should know there will be a lot of us who will remember what they did.
I guarantee you, if health care reform fails, the only time I'm going to vote Republican is for dog catcher. Then I'll get the meanest, nastiest dog I can find and set it loose.

More Complaining about Evidence-Based Treatment

The most recent edition of the National Psychologist contains two articles concerning evidence-based treatment. Unfortunately, the online edition hasn't been updated yet and the articles are only out in hard copy.

For those of you who are not of the cognoscenti, evidence-based treatment is simply treatment with a clear research base. The research establishes that certain procedures are helpful for certain types of problems. My previous post describes an evidence-based treatment for OCD.

The first article, by Thomas Habib, opens with a bizarre story. Apparently a managed care network, Managed Health Network, wants to establish a category of, what Habib calls, an "elite clinician." I'm not sure if it's Habib's words or theirs'; I couldn't find it on their web site. Essentially, this elite clinician would be someone who has been trained in and practices evidence-based treatment. I assume that these elite clinicians would be given priority in referrals.

Habib is worried about the perceived deadly combination of managed care and evidence-based treatment. He states,

No one is against evidenced based practices. As mentioned above, how this goal was pursued and the disregard of how this might strait jacket psychology and be misused by mangled care is the problem.

"Mangled care" is an obvious shot at managed care. Certainly somewhat deserved, but then, our hands aren't entirely clean, either. There have been far too many clinicians who weren't good at getting change, but were very good at keeping clients in therapy for extended periods of time.

Managed care credentialing for clinicians doing evidence-based treatment is silly. From experience, I know this will fail, because it won't save MHN any money. Back in the 1980's, when managed care blew into Pennsylvania, I spent an incredible amount of time on the phone with "care managers," who would authorize treatment for my clients. Once I learned what they wanted to hear, it was no problem to get sessions authorized. I got to know a lot of care managers by name and we'd chat about our families before getting down to business. But, eventually, telephone authorizations became too expensive, and most of my telephone friends had to get other jobs. Now, my secretary fills out a page, I add the diagnosis, and sign it. Bingo! Another 10 sessions.

So, let me assure you, Dr. Habib. This will end with a whimper, and you'll be left with a mild bit of bureaucracy. Nothing to get excited about. Managed care isn't going to hurt you with evidence-based treatment requirements because it's too expensive to do so.

But, is evidence-based treatment a "strait jacket?" Absolutely not, and the second article illustrates my point clearly. Surprisingly the author, Frank Dattilio, also thinks he's attacking evidence-based treatment. He should really know better, as he has extensive training and publication in cognitive-behavior therapy. In his article, he tells the story of Corey, a young psychiatrist completing his fellowship. Corey brought him a tape of a therapy session, of which he was very proud. Dattilio viewed the tape and said,

Much to my dismay, the same things kept cropping up repeatedly during the course of the session--a dry, robotic type of interaction that almost appeared as though it was scripted.

At the end, Corey said to me, "So what do you think?" I was speechless. Before I had a chance to say anything, he interrupted me by saying, "I think it's classic cognitive-behavior therapy. I don't believe I left one thing out."

"Well, there is one thing that is missing," I replied. Corey looked at me perplexed, "What did I forget?" "You!" I exclaimed, "You, the therapist is missing."

It's a wonderful story, and a great cautionary tale to young therapists, who, unsure of themselves, want to retreat into "techniques." Since the 1950's, we've known the quality of the therapeutic relationship has a strong effect on therapeutic outcomes. Wampold (2001) has a good review of the data. Maintaining a good relationship with the client, being empathic and supportive, is part of any evidence-based treatment. Just look at Beck, Rush, Shaw, and Emery (1979).

The sad thing is that we continue to argue about evidence-based treatment even though we consider psychology to be a science. If psychology is a science, we believe the data. If psychology is a science, we opt first for treatments that the data shows are worthwhile. No one expects us to give up our clinical judgment and our empathy in the process. Being empathic and supportive is just another evidence-based therapy.

All psychotherapies are like seeds. They cannot grow into a beautiful flower without the fertile soil that the humanity of a good therapist provides. Clinicians do not need to fear evidence-based therapies.

References

Beck, A. T., Rush, A. J., Shaw, B. F., & Emery, G. (1979). Cognitive therapy of depression. New York: Guilford.

Dattilio, F. M. (2006). Evidence based treatment may be too confining. National Psychologist, 15(5), 23.

Habib, T. A. (2006). A profession in search of legitimacy. National Psychologist, 15(5), 14.

Wampold, B. E. (2001). The great psychotherapy debate: Models, methods, and findings. Mahwah, NJ: Lawrence Earlbaum Associates.