Insurance coverage as psychopathology; single payer as the cure

By Sharon R. Kahn, Ph.D.
The National Psychologist, July/Aug. 2016

Can you top this? “My client has PTSD and her insurance would only authorize 10 sessions.” Another adds: "My client has Major Depression and insurance will only authorize pharmacological treatment, no psychotherapy."

Are we practicing evidence-based treatment modalities – or playing a deadly game of Go Fish? Clearly, we do not live in a sane society. How can we remediate this if we do not resurrect the zeitgeist of Erich Fromm, who drew back the curtain to show the "principle of free competition and the concomitant notion of the survival of the fittest called for individuals who were not inhibited by compassion in business dealing. Those who had the least compassion had the greatest chance of success." Or, became insurance executives.

I became a psychologist to heal and repair the psychic ruptures in people's souls. But I can't repair when the access is blocked. I cannot repair when a third party is reading my notes, deliberating if it looks substantial enough to reimburse for a 45-minute session –  or if reimbursing only for the lower, 30-minute rate is justified.

It's not just psychologists who suffer a loss of income. Over 33 percent of Americans cannot access needed medical care due to money. In fact, the United States is the only country in the world where citizens declare bankruptcy due to costs of medical treatments.

Most countries already have a national health care system. Some are socialistic in nature; others are a single­ payer system set within a capitalistic economy, such the Canadian model.

The difference between Canadian capitalism and the American is merely over who the payer is: the government, as opposed to diverse insurers. With the latter, payments are pawns to a false philosophy put forth by the insurance executives: Patients are wiser utilizers of medical services when they have "skin in the game" (i.e. copay).

Skin in the game restricts access, as between patients and practitioners when patients wonder whether practitioners recommend treatments based on what insurers will pay or patients reject recommended praxis due to fiscal concerns.

Access is further restricted when insurers use clerical personnel to review records and decide to reduce reimbursements based on their assessment of what best praxis should cost. Throw in a lack of true parity for mental health, vision and dental care and one can only wonder why a latter-day Samuel Adams (a disabled American) has not thrown all health insurers into some harbor.

The hypothesis of "skin in the game" has been disproven over and over. Medical costs become a de facto method to ration care, not rationalize it. A single-payer system would restore trust, increase access and reduce health care costs by paying hospitals, clinics and professionals a lump sum monthly.

Single payer is not socialistic, as professionals and hospitals remain privatized – they negotiate patient care with the patient – not with a third party. Professionals bill and are reimbursed by the state health department. Never again would clients hear that their insurance will not cover additional sessions. Or that their insurance insists that they take medications. No one receiving in-patient care will be harassed when their insurer calls and informs them they don't merit that level of care.

Under the Affordable Care Act (ACA), states are encouraged to innovate in health care systems. Every legal state resident would be covered regardless of age, income, savings or employment. A person desirous of medical care would simply flash an eligibility card in front of the receptionist to receive services. There are no co-pays or deductibles. Professionals bill the health department for services. Tests and prescriptions are all covered. True parity would be offered, not only medical, but mental health, dental and vision care.

The money is there, via the state's payroll taxes (paid 80 percent by employers, 20 percent by employees and I 00 percent by the self-employed). Non­ payroll income, such as capital gains, dividends and interest would also be used to fund single payer. Perhaps overall, taxes would rise – however, overall, costs for the individual would decrease – no more premiums, deductibles, co-pays and out-of-network minimums.

The average cost of an employer­provided family plan today is over $17,500 with an average family deductible of over $2,200. The average individual spends over $6,000 a year for health care premiums.

Overall health care costs will decrease as the profit that insurance companies demand (up to 30 percent of the health care dollar) will disappear. Administrative costs will decrease, as there will be no billing specialists whose job is to negotiate with insurance companies.

Under single payer, federal funds currently utilized for Medicare, Medicaid, Family Health Plus and Child Health Plus would be combined with the state revenue in a health trust.

The ACA (Obamacare) has failed to ensure universal coverage. It was based on the notion that federal aid would enable citizens to buy insurance via subsidies – it did not predict that insurance companies would then raise premiums to ensure profits would never be used to pay for health care costs, a perpetual game of keep away. Keep away does not bring down health care costs, as insurers are for-profit ventures with no incentives to make costs transparent.

The growth in the net cost of health insurance is due to administrative waste and executive profits. A single-payer plan would reduce spending by 15 percent by terminating billing expenses, administrative waste and fraud.

ACA further assumed that states would expand Medicaid coverage – and approximately half did not. One-third of Americans report they are now unable to access needed medical care due to cost. Thus current practice only serves to ration care; single payer offers a rational path to the sane society.

There is no justification for what passes for psychotherapeutic praxis today. True therapeutic conditions arise when clients and psychologists are freed to discuss all the empirically proven options. Psychologists once more could heal psychic deficits, offering the intensity of care individually titrated to the client's needs. It will happen when psychologists become so frustrated as to make their desires known to elected state and federal representatives. Single payer offers the route to a saner society replete with life, liberty and the pursuit of happiness.

References available from author.

Sharon R. Kahn, Ph.D., is a medical expert for the Social Security Administration and a consultant to the New York Metropolitan Transit Authority s Access-A-Ride program. She completed post-doc studies in narcotic and drug research. She resides and practices in New York, N.Y., where she advocates for a single-payer plan. Her email address is