AACP Newsletter, Volume 13,
Number 4, Autumn 1999
A Year in D.C. as a Robert Wood Johnson Public Policy Fellow
My year in the beltway ended with a bang and a whimper. Having recently succeeded in getting Senator Kennedy to do a major mental health policy speech that went quite well, and then working out his rather unusual legislative partnership with Jesse Helms on a colon cancer screening bill, I was feeling fairly satisfied with the year thus far.
The legislation I had worked on the hardest, the SAMHSA reauthorization, was successfully passed out of committee by an almost unanimous vote, something very rarely seen in these days of partisan bickering in the Congress. The bill contained many of the very progressive provisions that the Democrats had created and proposed, especially with regard to children’s mental health and substance abuse issues, psychological trauma, co-occurring disorders, seclusion and restraint, and the interface between mental health and primary care. There was the unfortunate inclusion of the charitable choice provision, which the Republicans insisted upon over the objections of the Democrats. The other provisions in the bill made it very difficult to oppose the entire bill over the constitutionally challenged faith-based provision, much of which has been discussed in some detail in the AACP listserv.
The bill now goes to the floor for approval, but late news from DC tells me that the whole bill may go up in smoke (so to speak) in that there is a late hour move afoot to attach an amendment to alter the penalties of the Synar amendment, the provision that requires states to monitor businesses to make sure that they don’t sell tobacco products to minors. The problem is that the penalties for states that are out of compliance are enormous (40% of their Substance Abuse Block Grant funding!), so the Secretary of HHS is trying to modify the penalties. This has become an enormous political problem and the Republicans are now apparently willing to kill the bill (or delay it for quite a while) in order to prevent the Secretary from succeeding in this effort.
A big surprise for me was being asked to give the keynote address to a rather large mental health conference at the DC Convention Center early in August. It turned out that I was filling in for the real keynoter, who suddenly had to leave town. “Who was it?”, I asked. “Tipper Gore.” Well, I was quite flattered to be asked to do the speech and somewhat surprised to be pinch-hitting for the 2nd Lady, but I managed to do it just the same, and I very much enjoyed the experience.
The last part of the summer was spent in tying up loose ends, passing on the baton to others within the Kennedy office on the issues with which I was dealing, finalizing a few negotiations on bills that were pending, and saying goodbye (through a series of unrelated, but sumptuous meals) to a whole string of people with whom I had become acquainted and whom I had drawn upon for advice. The year was a smashing success from a number of perspectives, especially in relation to the primary goal of learning about health policy and the legislative process.
In parting, I should muse on the question of whether the paradigm shift noticed in health policy in recent years has become a “paradigm stall”. I would say that things have indeed stalled. It may be due to the ever-present election cycle and the pervasive impulse to do nothing politically risky. It may be due to the more polarized dynamics of the Congress in the late 20th century. It may be due to the inherently confusing nature of the health care system as it has now evolved, given almost entirely over to the private sector and still struggling to become a “system” without any systematic planning or overall design.
In any case, this paradigm stall is unlikely to shift until the leadership in the White House and Congress express sufficient courage and willingness to address the lack of a coherent national health system head-on, rather than the current piecemeal and incremental approach that has been the preoccupation of most of the health care world for the last six years. It may require that things get decidedly worse (either through the general public’s more unambiguous expression of displeasure with the system or possibly through major class action law suits) before any politician will be willing to be so bold. Rather bleak outlook, if you ask me. The real question is how we, as community psychiatrists and other progressively minded participants in the system, will respond.
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