With the appearance of President Obama before the AMA House of Delegates
and delegates' staging a lengthy debate about the relative merits of a"
public option" for health insurance, the shape of a reformed U.S.
health system was front and center at this year's AMA Annual Meeting in
It was with virtually unanimous agreement and little debate that AMA
delegates also asserted the importance of including parity for mental illness
and substance abuse in any health reform plan. The resolution, brought by the
Section Council on Psychiatry, asserted in part that "psychiatric care
should be... an intrinsic part of medical care" and that "the
principles underlying mental health parity are part and parcel of what needs
to happen in any broad-scale health reform aiming at universal access, quality
improvement, and cost control."
Despite the passage last year of the Paul Wellstone and Pete Domenici
Mental Health Parity and Addiction Equity Act, parity for mental illness and
substance abuse under a newly reformed health system is not assured. For one
thing, the parity law is not applicable to individual or small-group
Additionally, a new plan could override the law by allowing—for
instance—low-cost plans that provide less robust coverage. Just days
after the AMA meeting, APA sent a letter to the Senate Health, Education,
Labor, and Pensions (HELP) Committee, asking the committee to close loopholes
in health reform legislation currently under consideration that could
undermine parity. The HELP committee reform law offers exemptions from parity
for insurance purchased through the health insurance "exchanges"
envisioned in the law; APA's letter asked that the parity law effectively be
extended to all insurance, citing the potential incentive for employers who
must comply with the parity law to drop insurance coverage and push employees
into the exchange market, where their employees would lose parity
At the AMA meeting, Donna Woodson, M.D., a Maumee, Ohio, family physician,
said she regularly treats patients with serious mental illness who should be
seen by a psychiatrist but can't because their insurance does not adequately
cover the treatment.
"The winds of change are upon us," she said, noting that the
AMA had asserted its support for parity coverage in previous policy
statements. "This resolution speaks specifically to inclusion of parity
in broad-scale health reform. This will assist our psychiatric colleagues, but
it really addresses what should be appropriate care for our
It was not the only section council resolution pertinent to the debate
around health system reform. Much of that debate focuses on the costs of
American health care, routinely said to be well in excess of other countries'
and to yield a poor return on the dollar in terms of health outcomes.
But AMA delegates expressed strong support for a resolution by the Section
Council on Psychiatry asking the AMA to reexamine those assumptions.
It calls on the AMA to "undertake a careful examination of the
reported cost estimates of the health care systems of comparable developed
countries, clarify the services and attendant expenses which are included in
such estimates, publicize any estimates which ignore costs shifted to other
parts of national budgets, and use this information" in debates about
health system reform.
Section council member Ken Certa, M.D., of Phildelphia, said the resolution
derived from conversations with physicians in other countries about how
certain health care services and costs were budgeted.
In many countries, he said, nursing-home services are under a
social-service budget, not a health care one. "But when we go to
Harrisburg [state capital of Pennsylvania] to lobby for health care programs,
they tell us half of the Medicaid budget is going to our nursing home
care," Certa said.
"Another discrepancy is that in other countries medical education is
essentially free" for students, he said. He cited a colleague whose
tuition from a Central American medical school was $10 a year, while American
students graduate with an average debt of $160,000.
That debt must be paid back out of physicians' earnings, making it one of
the drivers behind physician reimbursement rates. Moreover, graduate medical
education costs are largely borne by Medicare and some state systems;
meanwhile, medical graduates from all over the world vie to receive training
in the American system. ▪