With the majority of state legislatures done for the year, an overview of the activity from the state capitals shows it was a busy year for state psychological associations.
In the last several months, state legislatures took psychology-friendly positions on mental health parity laws and health insurance liability, increased state-to-state mobility and battled over efforts to protect the doctoral-level standard for independent practice of psychology.
"We have a number of tough issues we are working on internally and externally in the states," says Michael Sullivan, PhD, assistant executive director for state advocacy in APA's Practice Directorate. "It's heartening to see successes and forward progress being made by our state associations on a number of fronts."
State and federal legislation go hand in hand
Ever since the federal parity law, introduced by Sens. Pete Domenici (R-N.M.) and Paul Wellstone (D-Minn.), was passed in 1996, state legislatures have followed suit. Now, it seems that states could be leading Congress. Fifteen states now mandate mental health parity in health insurance for a broad range of mental illnesses, requiring insurers to offer similar coverage for those diagnoses that they offer for physical health diagnoses.
"The fact that so many states are enacting parity laws signals a real populist movement out there," says Sullivan. "There's truly broad grassroots support."
That support will certainly bolster activity at the federal level when the 1996 parity law sunsets later this fall and this issue comes before Congress again. A recent actuarial analysis by PricewaterhouseCoopers for APA shows that the cost of expanded mental health parity--specifically the cost of enacting the Mental Health Equitable Treatment Act proposed by Sens. Domenici and Wellstone this year--would be significantly reduced due to the passage of state parity laws.
Rhode Island joined the list this year by expanding its 1994 law, which covered only "serious mental illness," to include all mental illnesses. In addition this year, new Kansas and Illinois laws are mandating parity in health insurance coverage for "serious mental illness" only, bringing the number of states with "serious mental illness" covered in their parity laws to 21.
In addition, Delaware added a mandate for covering substance abuse to its requirement for covering serious mental illness. Mississippi passed legislation mandating coverage for inpatient and partial hospitalization. And by regulation rather than legislation, Arizona state employees now have broad-based parity for mental health coverage.
In another example of the interplay between federal and state actions, West Virginia and New Jersey joined seven other states and passed health plan liability laws to protect patients' rights. Under these laws, consumers can sue managed-care companies for negligence. This summer, the U.S. House and Senate had passed patient protection bills and at Monitor press time were scheduled to work out the differences in the two bills in a conference committee (see September Monitor).
The House version of the bill would pre-empt nine states liability laws--a provision APA does not support.
The battle for prescription privileges for psychologists continued to edge forward this year, with legislation introduced in nine states and hearings held in five--the most activity to date on the issue. The New Mexico Psychological Association surprised advocates across the country by getting a bill through the state House of Representatives, the first time that a bill has passed either chamber of a state legislature (See May Monitor).
The first prescription privileges bill could pass at any time, says Rochelle Jennings, APA prescription privileges coordinator. However, there may be less action in 2002, because many state legislatures only consider financial matters on even-numbered years.
Practice mobility has become a more pressing concern in recent years for two reasons: More psychologists are moving from state to state and many practitioners and state officials believe telehealth will be a greater factor, a move that may also require psychologists to get permission to practice in different states.
Three states passed new laws this year to provide better avenues for relicensure:
A law in Missouri allows psychologists to use any one of the three national credentials. But it also accepts psychologists who have been appropriately licensed for the past five years, with no disciplinary actions against them. The law also says that psychologists who seek relicensure in the state may have to take an oral exam.
A new Idaho law allows psychologists to be licensed if they hold the Association of State and Provincial Psychology Boards (ASPPB) certificate of professional qualification or if they meet the state's current education and credentialing requirements. The law also grants licensure to "senior" psychologists who have been licensed for 20 years, have practiced psychology for five of the last seven years and have met the state's continuing-education requirements for the last five years.
In Connecticut, a new law now allows the state to endorse licenses or certificates from states with requirements similar to or higher than its own. Psychologists with ASPPB's certificate of professional qualification can also be licensed by endorsement.
More states are accepting mobility standards through administrative action, rather than passing new laws, according to psychologist Stephen DeMers, EdD, ASPPB director of certification. Several states have reciprocity agreements with other states on licensure, or they are among the 10 states that have signed on to an ASPPB agreement of reciprocity.
Scope of practice
For years APA has worked with state psychological associations to protect the doctoral standard for independent practice. APA's stance, as recommended by APA's Council of Representatives, is that psychology has defined itself as a doctoral profession and that there are other avenues of independent practice for master's-level psychology practitioners, such as being a licensed professional counselor or marriage and family therapist.
Among the most significant actions this year, Tennessee passed legislation to move toward a single level of licensure over a number of years. Tennessee is the first state to act in accordance with the policy recommendations from Council regarding the phasing out of dual-level licensure. Its new law permits currently licensed master's-level practitioners, "psychological examiners," to upgrade their licensure status to "senior psychological examiner" once certain post-licensure conditions are met.
These senior psychological examiners, while having a different scope of practice than psychologists, will be permitted to practice independently in designated areas of practice if they were licensed before July 1991, or if they have five years of supervised experience and at least 200 hours of board-approved post-licensure continuing-education activities. After 2004, no further psychological examiner licenses will be issued. Psychological examiners licensed at that time will continue with that license, but no new professionals will be created and thus over time that professional level will be phased out.
The law also creates a level of practice for master's-level professionals called a "certified psychological assistant," who will work under the supervision of either a psychologist or an employing community mental health agency or state government agency. Tennessee Psychological Association's Director of Legislative/Professional Affairs Lance Laurence, PhD, indicates that this new position is needed for testing and other purposes in prisons and other agencies. The assistant position will only be certified, not licensed.
Meanwhile, the Arkansas Psychological Association (ArPA) after "massive efforts" was able to defeat legislation that would have given psychological examiners, who are master's-level practitioners, the right to practice independently under the psychology practice law, after three years of supervision. The bill had passed the state House of Representatives.
ArPA had offered a compromise to allow independent practice for master's-level practitioners under a new, completely different licensing board. One of ArPA's key negotiators, Glen White, PhD, noted that under the compromise "they would be in a position to be masters of their own fate and develop their own standards of practice."
However, master's-level individuals would not be allowed to use the term "psychology" or any of its variants in their titles, including psychological examiner. ArPA suggested that they could use terms used in other states, including licensed behavioral practitioner or mental health examiner. The master's level practitioners rejected that proposal, however. In the end, the legislature sent the issue to a two-year study committee that will allow both sides to present arguments.
In other action, a new Florida law clarifies that the title "psychologist" may only be used by licensed, doctoral-level psychologists. It removes an exemption that had allowed people trained at the master's level to use the title in certain jobs at state agencies and nonprofit mental health centers. According to APA officials, this type of exemption sets up a double standard of care. People who rely on public programs for health care could receive "second tier" treatment in some cases, says Sullivan. Florida is the first state to attempt to remove these exemptions, a battle APA Council supports.
On the other hand, new legislation in Kentucky went counter to APA policy. Faced with powerful political interests that seemed certain to convince the state legislature to allow--as it has in the past--independent practice for master's-level practitioners, the Kentucky Psychological Association (KPA) worked with master's-level professions and won compromise legislation to allow independent practice for those practitioners, but on stricter terms than had been proposed.
In place of proposals that would have given master's-level professionals autonomous functioning after two years of practice with no examination, the requirements include five years of practice; passage of the Examination for Professional Practice in Psychology at the independent practice level; passage of the oral exam in practice, law and ethics at the independent practice level; and endorsements by the candidate's board-approved supervisor and two other licensed mental health professionals familiar with the candidate's clinical work.
Meanwhile, Utah's state legislature created the classification of "Certified Psychology Resident." The law requires all postdoctoral individuals going into supervised practice prior to licensure to submit an application to the Department of Occupational and Professional Licensing (DOPL), be of good character, obtain continuing education, and meet with the psychology licensing board if requested.
Psychologist Nanci Klein, PhD, lobbyist for the Utah Psychological Association (UPA) says of the new classification, "I think having a specific identity creates a better situation for the resident." The certification gives postdoctoral supervisees a formal status for the first time that reflects their professional development in their workplace, she adds.
The issue became evident when a psychology resident violated a "major ethical principle," and the state DOPL said could it not sanction the individual and could not prevent the person from obtaining licensure, since the resident had not been under the jurisdiction of any oversight body.
Chris Wehl, PhD, chair of UPA's legislative committee, notes that the change will also allow residents to get the licensure process under way at the beginning, rather than the end, of their residencies.
Other state actions
In other developments:
The Maryland Psychological Association (MPA) won a change in the law this year that makes psychologists among the health-care practitioners who may treat minors 16 and older without the consent of a parent or guardian, under many circumstances. The law also says that psychologists can determine whether or not a minor has the capacity to consent to treatment. MPA had anticipated that legislators would oppose the change, but in the face of school shootings and other problems, they approved the change.
The West Virginia Psychological Association helped lead a coalition of provider groups that successfully lobbied for legislation to phase out, over 10 years, a special tax on health-care providers that is used to help make up the state's portion of Medicaid funds. The state will replace the funds with revenues from the state lottery. West Virginia and Minnesota are the only states that have such a tax.