By Mickey Skidmore, ACSW

Since 9/11 we have been preoccupied as a nation with “the war on terrorism”, and more recently on the military action in Iraq. Yet quietly and pervasively there has been an ongoing battle raging in our country for the last 10-15 years at least – “the Health Care Wars.” Initially it was patients who were the losers of this war, but soon physicians and a wide range of health care practitioners have also become fatalities of this battle which seems to have no end in sight. With our recent focus on the Middle East, many can easily empathize with the Iraqi people who have endured a decade of international sanctions under an already brutal regime. Yet, any effort in the past decade to reform our health care delivery system has been shredded by power base of the health care industry.

The last major reform effort by the Clinton administration, a decade ago failed to produce any results and punctuated just how powerful the health care industry status quo really was (or should I say is). The reason for this is both simple and obvious: those with clear professional and economic interests in health care far out number those directly or indirectly speaking for consumers..

Thus, the health care power base is comprised by three significant dynamics (Broder, 2003):

Those currently profiting from the existing system: managed care and insurance executives, academic and think-tank experts, government policy makers, and some health providers (physicians and hospital executives). Since the Clinton effort a decade ago, most proposals have centered on the stagnant and unimaginative proposal of insurance, or exploring ways to reduce the growing numbers of the uninsured. This is a classic status quo maneuver – build off the existing system of health insurance. Perhaps a more radical concept is needed to challenge the status quo – namely that insurance is far more likely to be the problem rather than the solution..

A second significant dynamic of the health care power base is the political-governmental system. With weak parties and a fragmented congressional structure, this system itself contributes further to multiple power centers, making consensus far harder to reach..

The third dynamic of the health care power base is our present political culture which is deeply distrustful of government. Ultimately, this raises a high barrier to overcome in reaching any kind of centralized health care systems found in most other advanced industrialized nations..


In general, insurance companies have been slow and sometimes resistant to providing adequate coverage for behavioral/mental health services. Moreover, many consumers are unaware that the standard requirements of most insurance carriers that do reimburse for outpatient treatments include: assessment of mental condition and diagnosis of mental illness as conditions for reimbursement. The “diagnosis” or social label(s) then essentially become part of your permanent insurance and health records [can you say “pre-existing condition!?”]. This is especially alarming when parents seek out mental health services for their children, who in all likelihood will have these social labels follow them throughout their lives. Furthermore, many health care consumers are becoming increasing aware of the compromises associated with advanced technology and risks to their privacy and confidentiality as well. It is simply naive to think that confidentiality is limited to you and your provider if you have authorized an insurance carrier to reimburse for your mental health treatment services (Skidmore, 1997).

There are many who have believed for some time that managed care and insurance companies (for the purposes of this writing, these terms are inter-changeable) have spun out of control. And make no mistake about it; this despicable reality is due to nothing short of greed. While managed care takes credit for the halting of run away healthcare costs, they skirt any responsibility for the emerging and increasing crises of healthcare consumers (Skidmore, 1998).

In the many years I’ve been practicing Clinical Social Work, I have witnessed a ruthless and systematic eradication of anything resembling “long-term” care of mental health treatment. Insurance companies generally will not pay for treatment of personality disorders, despite the fact that they are perhaps one of the most prevalent variables effecting the landscape of mental health treatment. Moreover, insurance companies (along with State governments) are making it increasingly difficult to access drug/addiction treatment. (How can it be less expensive to build and support jails and prisons rather than pay for clinical treatments?). Even state hospitals for the indigent (in North Carolina) no longer accept alcohol or drug related conditions; MR patients; and the longest term treatment available anywhere at best may be 90 days (Skidmore, 1998).

In addition to impact the power base of health care has on patients, there are tremendously negative effects on health care practitioners as well, which ultimately increases patient vulnerability. The mental health field finds itself threatened by the “violence of reductionism” on two powerful fronts. On one hand, the predictions of the promiscuous use of psychiatry to address a world of problems that are not biomedical and are unrelated to individual patients or their families (Detre & McDonald, 1997) may very well be upon us. This trend clearly dilutes the specialty’s focus and makes it what it should not be – a proposed solution to a growing plethora of social ills. Thanks in large part to the practices of managed-care medicine, psychiatry has been rapidly trivialized into psych evals and med checks. And many psychiatrists, intimidated by the comments and techniques of managed-care reviewers, capitulate. As one psychiatrist wrote, “Most of all, I am saddened when colleagues silently bow to this business pressure to do less in less time, as if it were proven to be better or more ethical treatment” (Skidmore, 1998). Patients, poorly served are losing trust in their physicians and in medicine in general.

It is clear that providing mental health services these days is a tough business, and will only become tougher and more complex. One of the reasons for this truth is our entrenched cognitive dissonance toward the power base of the current health care system which leads to an increasing prevalence of corrupt contracts (either overtly or covertly). At some profound levels, such paralysis has contributed to our society’s cavalier disregard for the potential for young lives and our denial about the erosion of the institution of the family. It also exposes how poorly we as a nation and culture have decided how we will care for our elderly and the place they hold in our society (Skidmore, 1998).

Rather than challenge the power base of the health care industry we have accepted their status quo, which in turn has led to a bazaar type of governmental and legislative logic. As we allow insurance and managed care companies to say “no” more and more to mental health treatments, in the next breath we are on the verge of saying that society has decided that substance abusers and the mental ill will ultimately be incarcerated as our primary method for addressing such concerns.

In North Carolina these issues and concerns have never been more relevant given the advancing eventuality of mental health reform. Despite a similar plan’s dismal failure in Michigan, such logic is prevailing in the NC legislature and in effect dismantling the established mental health system in the state – which was intended to be a safety net for the poor and disenfranchised otherwise unable to access private mental health care. Limited resources and lack of funds have certainly contributed to many of North Carolina’s difficulties when it comes to providing mental health care. The history of this issue also points to other variables as well, including: poor management of the overall state mental health system; inept management of mental health funding; lacking of political vision and will to adequately address mental health issues in the state as a priority just to name a few (Skidmore, 2001).

As managed care companies look for more and more ways to say NO to their consumers; and insurance companies develop increasing strategies to deny claims, we may be witnessing the erosion of mental health care. Eventually, this short sighted approach will result in revolving door recidivism (which will cost more than longer termed therapy or outpatient treatment), however, this trend will not change until there is a consumer and practitioner revolt resulting in significant legislation at the national and state levels. And do not allow yourself to be conned by the legislature. More insurance is NOT the answer. Managed care and insurance companies are an increasing part of the problem. We need another way. But it won’t happen until we insist upon it – and significantly challenge the power base of today’s health care industry (Skidmore, 1998).


1. Broder, D. Curing U.S. Health Care. Charlotte Observer, April 13th, 2003.
2. Skidmore, M. Can You Say “Class Action Law Suit?” (Feb 2001).
3. Cenziper, D. North Carolina’s Troubled Mental Health System. Charlotte Observer, Jan 22nd, 2000.
4. Skidmore, M. Corrupt Contracts. (Nov 1998),
5. Skidmore, M. (Editor) Managed Care Medicine. (September 1998).
6. Skidmore, M. In a Word … NO. (June 1998).
7. Skidmore, M. (Editor) Managed Care: Conspiracy of Greed in Contemporary Health Care. (April 1998).
8. Detre, MD, Thomas & McDonald, PhD, Margaret C. Managed Care and the Future of Psychiatry. (Archives of General Psychiatry, March 1997, Vol.54 [3]).
9. Skidmore, M. Insurance Based vs. Private Fee-For-Service. (March 1997),