Government Relations Issues and Updates

Dear NCCs,

NBCC, ACA and AMHCA are pleased to announce that on July 26, 2011, Secretary of the Army John M. McHugh signed Army Directive 2011-09, Employment of Licensed Professional Counselors as Fully Functioning Army Substance Abuse Program Practitioners. This directive authorizes “the Army Substance Abuse Program to employ licensed professional counselors and licensed mental health counselors as independent practitioners with a well-defined scope of practice.”

The directive also establishes credentialing and privileging standards for licensed counselors who seek employment through the Army Substance Abuse Program (ASAP). The criteria include the following:

• Successful completion of a master’s degree in counseling from a regionally accredited college or university that has its counseling program accredited by the Council for Accreditation of Counseling and Related Education Programs (CACREP) (Counselors who are already employed with ASAP or who have already entered the application process for an ASAP counseling position prior to the effective date of the directive do not have to meet the accreditation requirement.)
• Possession of a state license as a professional counselor or mental health counselor
• Achievement of the highest clinical level offere by their state licensure board
• Passage of th National Clinical Mental Health Counseling Examination

The directive became effective upon signature by Secretary of the Army McHugh on July 26, 2011.

We have been told that the directive is a temporary policy that allows counselors to practice independently until the TRICARE regulations are completed as directed by the FY 2011 National Defense Authorization Act (P.L. 111-383).

You may recall that the TRICARE regulations were due out by June 20, 2011, but the deadline was missed and we were told that it may be another six months or more. There is no requirement that the final TRICARE regulations establish the same criteria as this directive. NBCC, ACA and AMHCA continue to urge the Department of Defense to adopt broad TRICARE regulations that recognize all qualified professional counselors.

Qualifying counselors who are interested in ASAP positions should act quickly. The Army is in dire need of more counselors and recently launched a national hiring initiative described here: www.dodlive.mil/index.php/2011/08/army-urgent-to-hire-130-substance-abuse-counselors-asap/. The job announcements reference social workers and psychologists, but we have confirmed with ASAP leadership that these positions are available to professional counselors.

ASAP vacancies are posted here for interested counselors:http://medcell.army.mil/spotlight.asp?id=20

Our organizations are pleased with this step forward, but continue to encourage recognition of all qualified professional counselors. We invite counselors to report back on any challenges or successes they experience as the result of this new policy and employment opportunities.

Medicare recognition of counselors and MFTs remains mired in the politics of debt and jobs. While the cost of the proposal is modest in the context of the overall budget, every expense is highly scrutinized by legislators. Consequently, moving Medicare legislation has been a challenge.

While there is a bipartisan Senate bill providing Medicare recognition of counselors and MFTs (S. 604), the coalition continues to search for a House sponsor of a stand-alone bill. Having a sponsor from the majority party is critical to moving through that chamber, so the coalition has met with almost every House Republican on the committees of jurisdiction, as well as almost every Republican freshman. While there is interest and support from many, no representative has yet offered to sponsor. The coalition will continue to seek a champion and position the issue for inclusion in any viable health care proposal.

On September 15, 2011, Rep. Barbara Lee (D-CA) introduced H.R. 2954, which includes a provision to extend Medicare reimbursement to professional counselors and marriage and family therapists. Rep. Lee sponsored the bill on behalf of the Congressional Tri-Caucus—comprised of the Congressional Hispanic Caucus, the Congressional Black Caucus and the Congressional Asian Pacific American Caucus. The legislation has 71 cosponsors and includes a host of health care priorities for the three caucuses.

H.R. 2954 is the first House bill to provide Medicare recognition to counselors in the 112th Congress. The coalition of counseling and MFT groups has been lobbying for a stand-alone House bill since S. 604 was introduced by Sen. Ron Wyden (D-OR). Several representatives have expressed interest in the legislation, but the coalition is seeking strong bipartisan support before introduction.

On October 11, 2011, Sens. Kent Conrad (D-ND) and John Barrasso (R-WY) introduced the Craig Thomas Rural Hospital and Provider Equity Act of 2011, S. 1680. This bill was filed on behalf of the Senate Rural Health Caucus to identify health care priorities for rural legislators. Cosponsors include Sens. Tom Harkin (D-IA), James Inhofe (R-OK), Tim Johnson (D-SD), Amy Klobuchar (D-MN), Pat Roberts (R-KS) and Chuck Schumer (D-NY). The caucus recognizes the need for increased access to mental health professionals and included language providing Medicare recognition to counselors and MFTs in section 17 of the bill. S. 1680 provides another vehicle for moving this legislation and brings the total number of Medicare bills to three.

The struggling economy has complicated the prospects for Medicare legislation this year. Congressional energy is consumed by the debt crisis and the need to grow jobs and turn around the financial system. Before taking its August recess, Congress passed legislation to increase the debt limit by $2.4 trillion coupled with $900 billion in immediate cuts and $1.5 trillion to be cut by a supercommittee of 12 legislators (three House Democrats, three Senate Democrats, three House Republicans, three Senate Republicans). If the supercommittee fails to enact the required savings by November 23, automatic cuts will occur on December 23. The supercommittee has been meeting to identify areas of agreement.

All legislation is considered within the context of Congress’ focus on cutting spending and increasing revenue. While the counselor-MFT Medicare legislation is scored by the Congressional Budget Office to cost only $100 million over five years (inconsequential in budgetary terms), it is still viewed critically for increasing spending. Legislators have been hesitant to sponsor the legislation for fear of seeming indifferent to the budget situation. However, sweeping health care proposals to address the financial crisis also may represent opportunities for including the coalition’s Medicare language. The threshold for inclusion in any package remains high, but not impossible. The coalition will be exploring all avenues and seeking opportunities to include its legislation in any moving vehicle.

On March 17, 2011, Sen. Ron Wyden (D-OR) introduced S. 604, the Seniors Mental Health Access Improvement Act of 2011. S. 604 is identical to past Medicare bills and adds licensed professional counselors (LPCs) and marriage and family therapists (MFTs) to the list of recognized Medicare mental health providers.

S. 604 has six original cosponsors, including Sens. Barrasso (R-WY), Begich (D-AK), Brown (D-OH), Durbin (D-IL), Inouye (D-HI) and Johnson (D-SD). Sens. Boxer (D-CA) and Conrad (D-ND) signed on as cosponsors after introduction. The bill must pass the Senate Finance Committee, where Sens. Wyden and Conrad serve as members.

The coalition of counseling and MFT organizations is seeking to add cosponsors to S. 604, as well as identify a House champion. Several representatives have expressed an interest in a House bill and a sponsor is expected to be named soon.

The prospects for passage of the Medicare bill are unclear. The very tight budget environment creates a higher threshold for passing any legislation with an associated cost. While the cost of our provision is modest compared to the overall budget, every issue will be given increased scrutiny. The most likely vehicle for inclusion is legislation to halt increases in the physician payment scale that will be on the congressional agenda later in the year.

On Sunday, March 21, the House of Representatives passed the Senate health care reform bill, sending it to President Obama for signature. While language adding counselors to the list of Medicare providers made it through a preliminary vote in the House Budget Committee, it didn’t survive compromise with the Senate in the Rules Committee, thus ending its chance for inclusion in the final package.

NBCC, along with ACA, AMHCA, AAMFT, and CAMFT worked aggressively to get and keep our language in the reform package throughout the process. While the original House-passed legislation included our provision, the Senate bill did not. Development of the final product became a highly political process that hinged heavily on budgetary issues. Our cost was modest compared to the overall reform price tag, but all new spending was closely scrutinized and many similar provisions did not make it through this screening--including the social work Medicare priority relating to skilled nursing facilities. Success of the reform package was uncertain until the very end, when the House marshaled the votes to pass the Senate bill 219-212, along with a “reconciliation” bill on a vote of 220-211 that incorporates the House-Senate compromises. The reconciliation bill must still pass the Senate, but only 50 votes are required so approval is almost certain. Both measures will be sent to the President for signature.

While we did not succeed in final passage, we have again moved the ball even closer to the goal. We will continue our push for inclusion of Medicare counselor coverage in all relevant health care vehicles, and potential opportunities this year are already being rumored. Your advocacy efforts helped bring us to the brink of success and we hope you will keep up the calls and letters in our next big push. We cannot succeed without your help and will not stop until we get the ball across the goal line. If you have any questions, please contact NBCC at advocacy@nbcc.org.

Thank you for your support and perseverance.

Sincerely,

Dave Bergman
NBCC VP for Legal and External Affairs

The health care reform debate is in the final stages and Medicare recognition of licensed professional counselors remains under consideration. The congressional leadership is putting the final touches on legislation to be voted on in the House this week, and if passed, referred to the Senate and ultimately the President. While NBCC recognizes that NCCs hold a variety of positions relating to the overall health care reform proposals, we believe all counselors can support legislation that provides Medicare reimbursement to counselors. To make this happen, we urge all NCCs to contact your U.S. Representative and Senators to request inclusion of our Medicare provision in the final health care reform package.

To find your legislators, go to the following link and put in your zip code: www.congress.org/communicate. Then call the Capitol Hill switchboard (202-224-3121) and ask to be referred to your Representative and Senators. Not sure what to say? We’ve included a sample message (below):

“My name is [name] and I am a National Certified Counselor living in [city and state]. I am calling to urge inclusion of language providing Medicare coverage of professional counselors and MFTs in the health care reform package, as provided in Section 1308 of the House reform legislation.”

If you have any questions, please contact NBCC at advocacy@nbcc.org.

Thank you for your support.

Sincerely,
Thomas W. Clawson, Ed.D., NCC, LPC

Overview

The U.S. House of Representatives passed a health care reform bill (H.R. 3962) on November 7, 2009, that includes language adding professional counselors to the list of eligible Medicare providers. The Senate released its health care reform bill (substituted for H.R. 3950) on November 18; however, it does not include counselors as Medicare providers. NBCC continues to press to have Medicare recognition language included in the final health care reform package and urges all NCCs to contact their senators to help make this happen.

Background

Legislation adding counselors to the list of eligible Medicare providers passed the Senate in 2003 and 2005, and the House in 2007 and 2009. It has, however, never passed both chambers at the same time.

Health care reform legislation (H.R. 3200) with language providing Medicare reimbursement to counselors and marriage and family therapists (MFTs) passed three House committees of jurisdiction in July 2009. The three House bills were merged into H.R. 3962 and the combined legislation was passed on November 7, 2009.

Efforts to get similar language in the Senate Finance Committee bill (S. 1796) fell short in October 2009. The Senate HELP Committee, which doesn’t have jurisdiction over this issue, did not include it in the legislation (S. 1679) passed in September 2009. The two Senate bills were combined and placed in a House bill (H.R. 3950) that has been referred to the Senate. This bill does not contain counselor inclusion in Medicare, but changes will be made to it on the floor.

A critical procedural vote on Saturday, November 20, 2009, obtained the 60 votes needed to bring H.R. 3950 up for debate. Once revised on the floor, the legislation will need another 60 votes to pass the Senate. If approved, the Senate bill (H.R. 3950) and House bill (H.R. 3962) will be merged in conference and referred back to each chamber for final passage.

Action Needed

It is critical that senators understand the importance of including language providing Medicare reimbursement of counselors in the final health care reform legislation. This can happen on the Senate floor and during the conference negotiations. Senators need to hear from NCCs urging support for inclusion of Medicare reimbursement of counselors in the health care reform legislation.

Sample Message for Senators

“My name is [name] and I am a National Certified Counselor living in [city and state]. I am calling to ask Senator [name] to urge inclusion of language providing Medicare coverage of professional counselors and MFTs in the health care reform package.”

Health care reform has been a top priority for Congress and the Obama Administration during the summer and fall months. House and Senate committees have passed health reform legislation, and at the time of this writing, the committee process is ending and floor consideration will soon begin. As part of this process, NBCC, the American Counseling Association (ACA), the American Mental Health Counselors Association (AMHCA), the American Association for Marriage and Family Therapy (AAMFT), and the California Association of Marriage and Family Therapists (CAMFT) have been working as a coalition to get language providing Medicare reimbursement to counselors and marriage and family therapists (MFTs) included in the reform legislation.

Five congressional committees have jurisdiction over health care reform legislation, including three House (Ways and Means, Energy and Commerce, and Education and Labor) and two Senate (Health, Education, Labor and Pensions (HELP), and Finance) committees. The three House committees passed their reform legislation (H.R. 3200) in July, as did the Senate HELP Committee (S. 1679). H.R. 3200 includes language recognizing LPCs and MFTs in Medicare, but S. 1679 does not because the committee lacks jurisdiction. The final committee to consider health care reform legislation is the Senate Finance Committee. Markup on its America’s Healthy Future Act of 2009 began in mid-September. Despite significant coalition advocacy, the original mark introduced by the Chairman, Senator Max Baucus (D-MT), did not include Medicare coverage of counselors. Senator Blanche Lincoln (D-AR), sponsor of the stand-alone Medicare bill S.671, filed an amendment to add the language during markup, but was not able to get a vote on it. The Senate Democrats likely have the votes to move legislation out of the Finance Committee and to the Senate floor. Before this can happen, the Finance Committee bill will need to be merged with the HELP Committee bill. The content of the combined legislation will be critical to how it is received in the Senate and whether it can muster the 60 votes needed to avoid a filibuster.

On the House side, the three committee bills will also be merged together and brought to the floor. The House bills have greater similarity than the Senate bills, so that negotiation process won’t be as challenging. However, there are significant divisions between Democratic liberals and moderates in the House, so the final version will also face obstacles based on its content. If the two bills can be approved on their respective floors, they will be sent to conference for reconciliation. This too will be a complicated and political process that will help shape the future of health care and determine the final bill’s likelihood for adoption. While there is language in all three House bills providing Medicare recognition of counselors, it will be a fight to keep the language in conference.

NBCC will be working with our certificants and coalition members to see this through to passage.

On November 1, 2011, NBCC, along with the American Counseling Association (ACA), the American Mental Health Counselors Association (AMHCA), the American Association for Marriage and Family Therapy (AAMFT), and the California Association of Marriage and Family Therapists (CAMFT), met with staff from the U.S. Office of Personnel Management (OPM). The meeting was with the Manager of Classification and Assessment Policy to discuss the creation of occupational series for the counseling and MFT professions. Without their own occupational series, counselors and MFTs employed by the federal government are often limited in pay and promotion, and hold titles that do not accurately reflect their professional identity, training and education.

The meeting was requested in response to a May 31 letter from OPM to the Department of Veterans Affairs (VA) indicating that the agency would not be immediately creating an occupational series for our professions. OPM indicated that it is in the process of reviewing occupational groups and would consider development of new series when the 100 series is reviewed. Seeking clarity and a stronger commitment, the coalition of counseling and MFT organizations contacted the House Oversight and Government Reform Committee and the Senate Homeland Security and Government Affairs Committee. Committee staff helped facilitate a meeting between the coalition and OPM.

The meeting was very productive and helped educate OPM about the counseling and MFT professions. While there was no formal commitment to create new occupational series, there seemed to be an inclination to at least explore it. The coalition will continue to work with the OPM to facilitate the process and encourage the development of new series.

On May 31, 2011, the U.S. Office of Personnel Management (OPM) issued a letter to the Department of Veterans Affairs (VA) indicating that the agency would not immediately be creating an occupational series for professional counselors or marriage and family therapists (MFTs). The OPM indicated that it is in the process of reviewing occupational groups and would consider development of new series when the 100 series is reviewed.

NBCC has been a strong proponent of the development of an occupational series for professional counselors since before the profession was legally recognized within the VA. Creation of an occupational series for counselors is integral to federal government employment and national parity. Failure to create an occupational series forces counselors who work for the federal government to be employed in:

• Generic series with no professional identit
• Established nonclinical series lacking independent practice rights with limited pay and promotion.
• Social work or psychologist series that are not available to most counselors and misrepresent their training and education.

The effort to obtain an occupational series took a big step forward in 2006 when Congress enacted legislation authorizing the employment of counselors in the VA. To create a series, a federal agency must request one from OPM. NBCC pressed VA Assistant Secretary for Human Resources and Administration John Sepulveda for an occupational series during a group meeting on the new law in September 2009. Mr. Sepulveda committed to the issue and followed through on that commitment, submitting a request to OPM in 2010.

NBCC is dissatisfied with the open-ended time line and has been pressing for more timely action. The coalition of counseling and MFT organizations has communicated with the staff of the House Oversight and Government Reform Committee and the Senate Homeland Security and Government Affairs Committee to discuss legislative and administrative options. The committee staff helped to facilitate a coalition meeting with OPM staff on November 1. The meeting was very productive and the groups were given a tentative time frame of fiscal year 2013 for potential commencement of the development process. While OPM did not guarantee that it will create the series, and the timeline is tentative at best, the process is moving in the right direction and the coalition will continue to press for prompt action.

Presently, counselors are not recognized as health care providers by the Indian Health Service (IHS) and are not eligible for funding through the IHS Scholarship Program. NBCC decided to take action on this issue after a report was released in September 2011 showing a shortage of mental health professionals in American Indian and Alaska Native (AI/AN) communities and revealing a hodgepodge of “counselors” (licensed and unlicensed) serving this population.

While the issue is new, NBCC has had meetings with the offices of several members from the Senate Indian Affairs Committee. The Senate meetings were productive and uncovered some early interest and support. However, because the IHS is no longer reauthorized every six years, the language must move through a stand-alone bill or some other omnibus bill that includes this type of provision.

NBCC has invited the American Counseling Association (ACA) and the American Mental Health Counselors Association (AMHCA) to participate in the initiative, and the three groups are collaborating on a strategy for success. The issue will take some time to develop and mature, but the foundation is being laid to allow American Indians increased access to the behavioral health services of professional counselors.

The Role of Government and Lobbying in the Creation of a Health Profession: The Legal Foundations of Counseling,” published in the Journal of Counseling and Development, provides the legislative history of the counseling profession along with priorities for the future.

Bergman, D. M. (2013). The role of government and lobbying in the creation of a health profession: The legal foundations of counseling. Journal of Counseling & Development, 91: 61-67.doi: 10.1002/j.1556-6676.2013.00072.x

On January 10, 2012, NBCC participated in a roundtable hosted by the White House Joining Forces initiative. First Lady Michelle Obama and Dr. Jill Biden created Joining Forces to improve the lives of service members, veterans and their families. NBCC was invited to the roundtable along with the leadership for more than 30 major health care associations.

The roundtable was a forum to discuss health care issues, with a focus on post-traumatic stress disorder (PTSD) and traumatic brain injury (TBI). Joining Forces teamed with the Joint Chiefs of Staff to address short-term opportunities for expanding collaborative partnerships between the Department of Defense (DoD), the Department of Veterans Affairs (VA) and the private sector. The meeting was preceded by a tour of the National Intrepid Center of Excellence (NICoE) located in Bethesda, Maryland. NICoE is DoD’s world-class facility for wounded care, and a leader in advancing TBI and psychological health treatment research and education. Among the distinguished speakers at the event was Admiral James Winnefeld Jr., vice chairman of the Joint Chiefs of Staff.

First Lady Michelle Obama opened the roundtable with a passionate discussion of the need to honor our service members and veterans. Dr. Robert Petzel, VA undersecretary for health, and Dr. Jonathan Woodson, assistant secretary of defense for health affairs, also spoke of their departments’ commitments to this cause. NBCC is committed to the White House initiative and to ensuring that counselors are properly trained in the treatment of PTSD, TBI and other issues affecting military personnel.

Paris 2008 – NBCC has used its official status with the United Nations Educational, Scientific and Cultural Organization (UNESCO) to advocate for counseling as a component of the agency’s education policies and programs.

Executive Vice President Ted Iliff represented NBCC at the biennial General Conference held at UNESCO headquarters during the last half of October. NBCC was invited to participate in the conference because of its status as a non-governmental organization (NGO) partner in official relations.

While attending the Education Commission strategy and planning meetings, Iliff noted that UNESCO documents and statements concerning its keystone “Education for All” (EFA) initiative spoke of a holistic approach to fostering education. However, they made almost no reference to any form of guidance or counseling.

During the commission’s debate on EFA, Iliff raised the issue of counseling’s benefits to the more than 60 national delegations attending the session.

“Counseling is a set of skills that can be taught at various levels of complexity to fit a school’s cultural, social and economic environment,” Iliff said.

“Training in counseling skills can help teachers and other school personnel identify signs of stress, trauma, depression, addiction, abuse and many other mental health problems that threaten a child’s development. Add career or vocational counseling, and you enter into the realm of sustainable development.”

Iliff quoted from a UNESCO report on EFA progress that cited concerns about gender inequality, poor attendance and high drop-out rates, among others. He said counseling can help educators deal with all those problems.

UNESCO’s new assistant director-general for education, Nicholas Burnett, later told Iliff that he welcomed the comments about the value of counseling and would consider those points as he formulates new policies related to achievement of EFA goals.