The last major legislation which President Trump signed was the Coronavirus Response and Relief Supplemental Appropriations Act (P.L.116-260). This legislation provided $1.4 trillion for the Fiscal Year 2021 federal government funding and $900 billion for the provisions to address the COVID-19 pandemic. Aimee Grace, formerly on the staff of Hawaii’s U.S. Senator Brian Schatz: “It has been said that budgets are moral documents.  As such, understanding how much the federal government invests in children is critical to know how we as the United States are investing in our future. As a starter, the term ‘child’ appears in the final 5,500-plus pages nearly 320 times.”

The House of Representatives report included several items of considerable interest to psychology and nursing: * “Clinical Psychological Training for Public Health Service Corps – The Committee supports the review by the Surgeon General’s office to update HHS regulations in order to permit the graduates of the 43 doctoral programs in clinical psychology accredited by the Psychological Clinical Science Accreditation System (PCSAS) to be employed by the Public Health Service Corps. This update is necessary as PCSAS was recognized in September 2012 by the Council for Higher Education Accreditation (CHEA) and now accredits 43 programs that are among the highest-ranked clinical psychology program in the country. The Veterans Administration, the Association of Psychological Postdoctoral and Internship Centers, and others have already updated their regulations to permit the employment of the graduates of PCSAS accredited programs. The Committee urges the Surgeon General’s office to finalize and implement these changes as soon as possible.”

Alan Kraut, the Executive Director of the PCSAS (formerly with APA and APS), has been similarly successful in having the Senate report encourage HRSA to update eligibility requirements for the Behavioral Health Workforce Education and Training Program for Professionals and the Graduate Psychology Education Program (GPE), to account for accreditation changes that have occurred since the eligibility requirements were established.  “The Committee notes the Council for Higher Education Accreditation, as well as the Department of Veterans Affairs, recognizes the Psychological Clinical Science Accreditation (PCSAS). HRSA is encouraged to make administrative updates to ensure that HRSA’s health workforce programs continue to have access to the best-qualified applicants, including those who graduate from PCSAS programs.” PCSAS graduates are now recognized for licensing in states that represent almost 30% of the U.S. population, including the high population states of New York, California, and Illinois.

* “Graduate Assistance in Areas of National Need (GAANN) – The Committee recommends $24,047,000….  GAANN provides fellowships through grants to degree-granting postsecondary institutions, for students of high financial need studying in areas of national need. The Department consults with appropriate agencies and organizations to designate the fields of study ‘in areas of national need.’ GAANN offers innovative graduate education programs, with associated fellowship opportunities, at the intersection of humanities, arts, STEM, and health-associated fields in order to prepare our national graduate students for increasingly interdisciplinary global challenges. Recent examples include computer and informational sciences, engineering, nursing, and physics.

“Since 2012, an academic area related to health professions has only been designated once. It is estimated that more than 18 percent of the U.S. adult population has suffered from any mental illness. Mental health is clearly an area of national need. The Committee directs the Secretary to consider the inclusion of academic areas that fall under the Classification of Instructional Programs (CIP) 51.15 Mental Health Services on the next grant competition.”

* “Mental and Substance Use Disorder Workforce Training Demonstration – The Committee includes $41,700,000 for the Mental and Substance Use Disorder Workforce Training Demonstration program….  This program makes grants to institutions, including but not limited to medical schools and FQHCs, to support training for medical residents and fellows in psychiatry and addiction medicine, as well as nurse practitioners, physician assistants, and others, to provide SUD treatment in underserved communities. Within the total, the Committee includes an additional $15,000,000 for new grants to expand the number of nurse practitioners, physician assistants, health service psychologists, and social workers trained to provide mental and substance use disorder services in underserved community-based settings that integrate primary care and mental and substance use disorder services, which may include establishing, maintaining, or improving academic units or programs to support those activities….”

And, * “CMMI Strong Start Initiative – The Committee continues to be concerned that the U.S. spends significantly more per capita on childbirth than any other industrialized nation – with costs estimated over $50 billion annually – but continues to rank behind almost all other developed countries in birth outcomes for both mothers and babies, including high rates of preterm birth, low birth weight, and high maternal and infant mortality. The Committee is aware that the CCMI Strong Start Initiative, as well as other research studies, have shown that models of care utilizing Certified Nurse Midwives, birth centers, and licensed doulas are associated with higher patient satisfaction and improved outcomes for mothers and infants. The Committee looks forward to the report, requested in House Report 116-62, that would build on the CCMI Strong Start Initiative to develop a proposal for CMS to increase access to birth centers and midwives in all state Medicaid programs, and incentivize this model of care for low-risk women.”

The Steady Maturation of the RxP Agenda

Jin Lee, Chair of the Colorado Prescriptive Authority Taskforce (CO RxP): “I recently distributed a survey inquiring the Colorado psychologists’ interests and support in Colorado for RxP.  The results indicated that nearly 90% of the respondents (130/145) were either somewhat or fully supportive of this initiative, and 61% (89/145) were either somewhat or fully interested in pursuing the advanced training upon passing the legislation. Based on the overwhelmingly positive support from the psychologists in Colorado, we are preparing to introduce the legislation in 2022.  Colorado is ranked the second-worst state (48^th/50^th) given the high prevalence of mental health concerns and lack of access to care. Colorado has the highest rate of deaths by drug overdose in the U.S., and in 2019, African American Coloradans had the highest death rate from drug overdose, which is 18% higher than the national average. While the national average of available psychiatry services is 8.9 per 100,000, the ratio in Colorado is 8.6 per 100,000. Suicide is the second leading cause of death among teens and young adults in our state. Given the crisis of mental health and the significant shortage of mental health providers, obtaining the prescriptive authority for psychologists will help bridge the critical gap in mental health support demands. I am in the process of discussing a potential opportunity to establish an MSCP program at a university in Denver. I am also in the process of discussing with several primary care and family medicine clinics to build a partnership and create practicum opportunities for those who are pursuing RxP in Colorado. I am hopeful that Colorado joins the other five states that passed their bill and many others who are in the process of passing the legislation.”

Having fulfilled my clinical internship year at Ft. Logan Mental Health Center in Denver, which at the time was at the forefront of the community mental health center movement, I was particularly pleased to learn of Jin’s efforts. She reminded me of the late-Chuck Faltz’s observation that when the California Psychological Association got involved in RxP, their membership significantly increased as they were addressing a real interest of their constituency.  For those involved in the RxP movement, the recent American Psychologist article highlighting the revised 2019 standards for APA’s model psychopharmacological training for prescriptive authority should suggest significant progress in this evolution.

Looking Back with an Eye for the Future

With the advent of the new Biden Administration, it seems most appropriate to look back at past policy recommendations.  In 2006, the Institute of Medicine (IOM) (now, the National Academy of Medicine) released its report Improving the Quality of Health Care for Mental and Substance-Use Conditions. The then-President of the IOM: “The committee calls on primary care providers, other specialty health care providers, and all components of our general health care system to attend to the mental and substance-use health care needs of those they serve. Dealing equally with health care for mental, substance-use, and general health conditions requires a fundamental change in how we as a society and health care system think about and respond to these problems and illnesses. Mental and substance-use problems and illnesses should not be viewed as separate from and unrelated to overall health and general health care…. To this end, the Institute of Medicine will itself seek to incorporate attention to issues in health care for mental and substance-use problems and illnesses into its program of general health studies.”

At that time, it was estimated that more than 33 million Americans used mental health services or services to treat their problems and illnesses resulting from alcohol, inappropriate use of prescription medications, or illegal drugs. These conditions were the leading cause of combined disability and death among women and the second-highest among men. An earlier IOM report Crossing the Quality Chasm, put forth a strategy for improving health care overall, which attained considerable traction in the U.S. and internationally. However, health care for mental and substance-use conditions had a number of distinctive characteristics, such as the greater use of coercion into treatment, separate care delivery systems, a less developed quality measurement infrastructure, and a differently structured marketplace. These raised questions about whether the IOM proposed approach was applicable, which this later report found it was, with mental health and substance-use health care and general health care sharing many characteristics. Further, there was evidence of a very strong link between the two, especially with respect to chronic illness and injury.

The 2006 IOM report recommended that to facilitate the development and implementation of core competencies among all mental health and substance-use disciplines, institutions of higher education should place much greater emphasis on interdisciplinary didactic and experiential learning and bring together the faculty and trainees from their various educational programs (i.e., IPE). Mental health and substance-use health care – like general health care – was found to be “often ineffective, not patient-centered, untimely, inefficient, inequitable, and at times, unsafe.  It, too, requires fundamental redesign.” The underlying questions: In the decade-plus since this IOM report, have we made the types of fundamental changes that are necessary? And, have we enthusiastically embraced integrated care?

We also took this occasion to review a number of old newspaper columns, which at the time I thought might be useful in crafting speeches or federal legislation. For example, in August 2004, “15 Illnesses Drive Up Costs,” with mental disorders being listed in the third spot. This article noted that “Although Americans spend more per capita on health care than citizens of any other industrialized nation, numerous studies have suggested the investments have not resulted in a healthier population.” In July 2005, “The Next Phase in Psychiatry,” announcing the largest ever studies in drugs for depression, schizophrenia could transform treatment. Their aim was to fill the information gap that plagues psychiatry and hurts the quality of care given to patients. That is, that the clinical trials that companies conducted to get drugs approved aren’t designed to provide the answers to questions that doctors say are really needed. And “After 12-Year Quest, Domenici’s Mental-Health Bill Succeeds” (October, 2008). The importance of exercise, electronic medical records, disease management, and the ever-escalating costs of health care were regularly noted.

My favorite appeared in April 2004 – “In the ‘50s, Authorities Fought Source of Ruin of Teens: Comic Books!” “The (U.S.) Senate subcommittee wishes to reiterate its belief that this country cannot afford the calculated risk involved in feeding its children a concentrated diet of crime, horror, and violence.” A senior psychiatrist, who specialized in treating children with behavior problems, noted that without exception, every troubled child he had encountered loved comic books, reading as many as 20 a week. Without these graphic examples, he wondered, would young people really carry switchblades and have rumbles? Although the subcommittee ultimately did not recommend federal regulation of comic books, publishers felt the “chilly breeze” of potential censorship. When their code of decency took effect in late 1954, “the vast majority of crime and horror comic books disappeared from newsstands. But by then, America’s children were becoming addicted to a new and far more sinister medium: television.” “If you join us right now, together we can turn the tide” (Hamilton).

Aloha,

Pat DeLeon, former APA President – Division 29 – February 2021

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Pat DeLeon, Ph.D.