Assembly Backs Clinton Call for Opening Up Medicare

Members of the APA Assembly overwhelmingly supported the Clinton Administration's proposal to make Medicare available to some Americans younger than age 65.

The initiative would allow individuals aged 62 to 64 who have retired or are not covered by employer-provided health insurance and those aged 55 to 61 who have lost their jobs to obtain coverage-at significant cost-through the Medicare program.

The White House proposal estimates that those persons would pay between $300 and $400 a month for the coverage. The former group would also be assessed a surcharge on top of their Medicare premium once they reach aged 65.

It was the Washington (D.C.) Psychiatric Society representatives who introduced the motion to have the Assembly back Medicare expansion. These representatives rejected the argument that employers would be more responsive than the federal government to health care concerns of working Americans.

The representatives noted as well that even though many psychiatrists are distressed by some aspects of Medicare, such as private contracting restrictions and evaluation and management coding regulations, "agreeing to this expansion puts us in a better position to demand change in Medicare than to walk off the playing field."

The Assembly's vote calls for APA to support Clinton's Medicare expansion proposal while continuing "to champion the removal of Medicare's undesirable procedures, policies, and discriminations."

The Assembly action must be endorsed by the Board of Trustees before APA's Division of Government Relations can move on it. The proposal is not high on the agendas of either the Senate or House of Representatives, however, so prospects for any urgent APA involvement and advocacy are uncertain.

The Assembly acted on a broad array of national issues and internal considerations during its three days of deliberations in Toronto just prior to the official opening of the APA annual meeting.

• In a lopsided vote, the representatives rejected a call to impose term limits on Assembly members. Introduced by George Fouras, M.D., the early career psychiatrist (ECP) representative for Area 6, the proposal noted the difficulty of members' becoming involved in policymaking aspects of APA in light of the infrequency with which positions turn over. His paper cited complaints he has heard from members who feel "disenfranchised from the system" because of a lack of opportunity to gain elective office in the Assembly and charges that the Assembly is not representative of APA members. He suggested limiting representatives to two consecutive terms, with at least a two-year hiatus before they would be eligible to run again.

  The sentiments of Westchester County representative Barry Perlman, M.D., however, seemed to carry the day. Perlman emphasized that "term limits don't work in the outside world, and they won't work here."

  Brooklyn representative Seymour Gers, M.D., pointed out the difficulty some small district branches have in recruiting any candidates willing to devote the time necessary to serve in the Assembly, and that it was thus a bad idea to reduce the pool of volunteers willing to serve APA.

  In other actions, the Assembly

• Voted to urge all district branches, chapters, and state psychiatric societies to consider adjusting the dues they levy on ECP's to bring them in line with the graduated national dues structure APA uses. With a recent survey of ECP members showing dues levels to be the most critical issue in their decision to join or retain APA membership, proposal authors Marylinn Markarian, M.D., ECP deputy representative for Area 4, and Ann Maloney, M.D., Area 2 ECP representative, pointed out that their early career colleagues are the group most likely to drop APA membership. They noted that while several district branches have followed APA's lead in instituting a system of graduated dues increases for psychiatrists transitioning from member-in-training to general member, the majority have not taken that step. They view this as a potentially effective method for increasing membership retention.



• Considered a proposal from the Commission on Psychotherapy by Psychiatrists and the Committee of Residents and Fellows that addressed the troubling decline in the opportunities for residents in all fields to receive psychotherapy. The resolution the Assembly strongly endorsed says that APA "affirms that medical students and residents in all fields of medicine, especially psychiatric residents, should have access to psychiatric services including psychotherapy by a psychiatrist, when available, on a par with all other medical services. Training programs should ensure that such services are available, affordable, and accessible during working hours and free of stigmatizing or discriminatory consequences." It also highlighted the importance of strictly maintaining confidentiality.



• Endorsed a recommendation from the APA Ethics Committee for a change in the wording of the Principles of Medical Ethics With Annotations Especially Applicable to Psychiatry concerning exploitation of patients. The current wording reads: "The patient may place his/her trust in his/her psychiatrist knowing that the psychiatrist's ethics and professional responsibilities preclude him/her gratifying his/her own needs by exploiting the patient. . . ." Because there are instances in which a psychiatrist reviewer who never saw the patient makes treatment decisions-someone in whom the patient never placed any trust-the wording is changed to: "A psychiatrist shall not gratify his/her own needs by exploiting the patient."



• Approved a position statement urging a cessation of nuclear weapons testing and the abolition of nuclear weapons.



• Referred to the Council on Economic Affairs an action to determine whether case payment contracting is unethical.



• Defeated a proposal to produce a 15-minute video of the Assembly in action.



• Referred to the Council on Economic Affairs and the Board of Trustees an action asking APA to explore whether purchasing cooperatives are a viable alternative to employer-financed health care or Medicare expansion.



• Approved the development of a strategy to increase access to psychiatrists for people with Alzheimer's disease and other dementias.



• Approved APA's development of policies designed to encourage dialogue with criminal justice officials to facilitate the identification of people inappropriately imprisoned as a result of mental illness and to avert future inappropriate incarceration.



• Asked appropriate APA components to review APA policies on physician health and develop new policy guidelines to address specifically ways to prevent suicide among residents and other physicians and to report back to the Assembly in November.
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• Defeated a proposal to move the APA central office out of Washington, D.C.