Affordable Care, Accountability: Whither Autonomy?

The Affordable Care Act (ACA) hangs uncertainly over the environment. Increased regulation and consolidation of care is most likely the future and will create a different landscape for health care providers, particularly psychotherapists. California has already received millions of dollars from the US government to set up a health insurance exchange that will be the marketplace for individuals and small businesses to purchase health insurance.  According to Katherine Nordal (1). The drive to reform health care delivery systems is well underway with hospitals and large medical specialty groups developing the blueprints for how services will be organized. January 2014 is the target date for implementation of the ACA.

Psychotherapists have been able to preserve a sanctuary for individual private practice over the last 20 years as medicine has shifted to larger group practices and many public sector therapists have had to implement cost-saving “evidenced-based” treatments.  The structure and paradigm of psychotherapy is not likely to remain untouched by the ACA.  The foundation of this paradigm has been the relational contract between therapist and client who have had the autonomy to collaborate on mutually determined treatment. This foundation has supported the development of diverse, multi-theoretical perspectives and treatment approaches allowing therapists to practice in two domains: 1) helping clients alleviate symptoms, and 2) helping clients grow emotionally.  Emotional growth represents a higher order change that involves the transformation of deeply embedded belief systems about self and others and their accompanying behavioral patterns. This second order change takes time.

Three ideas dominate the discussion of the ACA, and will play a critical role in shaping healthcare: affordability, accountability, and integration of care. The incentive to contain costs will most likely lead to a change in the fee structure. Fee for service has contributed to the escalation of healthcare costs by reinforcing utilization. (1) Global payments, echoing the earlier notion of capitation, represents a cost-cutting model where fixed fees for patient care will be pre-set and health care providers will need to work within these budget constraints.

Accountability is the therapist’s Achilles heal.  While privacy and confidentiality are the pillars of therapy, accountability has been regarded suspiciously. Therapists have been accountable to the client and to their theoretical orientation that establishes implicit parameters for the evaluation of change. The evaluation of psychotherapy progress is a sensitive, complex, intersubjective process. Yet when therapy is a covered benefit, the insurance company is contractually entitled to information. Therapists have resented this intrusion. Within the systems of care that will emerge, therapists will be held accountable for the effectiveness of their treatment. Evidence-based treatments and outcome measures will most likely be employed to determine what treatments can be provided, and to assess their effectiveness. This eventuality will not only affect the mental health of therapists but will also impact how therapy is practiced, taught and conceptualized.

Integration of care is the more complex and indeterminate part of the ACA and reflects how healthcare will be organized across the continuum of services from hospitals, specialty groups, primary care, and mental health services. Key words such as wellness, prevention, collaboration, and interprofessionalism sprinkle discussions about the ACA.  Will psychotherapists become part of large primary care groups or will they maintain their geographical distance without sacrificing their autonomy?

The emphasis on integrated, cost-cutting systems of care threatens the autonomy of the individual provider and the paradigm that supports emotional growth and the time-stilled, non-linear paths this growth follows. These changes concern me since the value that psychotherapy offers to our culture is a place to care for the Psyche. As a psychoanalytically oriented psychotherapist, I fear these changes. I realize reluctantly that I will have to move outside my comfort zone to adapt to the future.

It is imperative for therapists to educate themselves about the ACA in order to understand how their practice will be affected and what new opportunities will emerge.  With certain doors closing, other doors will open. What specialties will emerge as the result of therapists working with primary care? Not only will there be more individuals covered by insurance, but mental health services are considered an essential health benefit that will lead to greater utilization of these services.

It will also be important to work collaboratively with professional organizations to advocate for your profession. Change is often a top down process. The big power holders typically make the big decisions.  The individual practitioner is not a power holder and will have no impact on the shape of changes set in motion by the ACA.

Bion (2) speaks about the creative process that is involved in learning from experience and change.  Creativity involves the dismantling of old models of viewing the world in order to allow for the emergence of new ideas that often are regarded by the psyche as well as by the social group as threatening. Personal belief systems are containers that ground the individual in a familiar reality.  Change involves rattling and breaking the container and the ability to tolerate disruption and anxiety. The capacity for transformation involves both the acceptance of the limitations of external reality, and the lessening of one’s omnipotence and one’s attachment to old belief systems.

1. Nordal, K.C., (2012) Healthcare Reform 2012: Implications for Professional Practice, The California Psychologist, Nov./Dec. 2012.

2. Bion, W. (1977)  Seven Servants,  Jason Aronson


Find out more about the effects of the ACA on psychotherapy practice in Health Care Reform: Preparing the Psychology Workforce  by By Ronald H. Rozensky, Ph.D

Psychologists check Capitol Notes for updates on The ACA

Check out the California Care website  set up by the State of California for individuals and small businesses to purchase health insurance mandated by the ACA.



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Larry Brooks, PhD

Licensed Clinical Psychologist
License # PSY 8161

138 N. Brand #300
Glendale, CA 91203
(818) 243-0839


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