State of the Nation’s Health Care 2010
The Declining State of the Nation’s Health Care
And the Urgency of Moving Forward on Essential Reforms
Robert B. Doherty
Senior Vice President
Governmental Affairs and Public Policy
The American College of Physicians
Thank you, Dr. Stubbs for your eloquent statement on why your patients need comprehensive health care reform.
I am Bob Doherty, ACP’s Senior Vice President of Governmental Affairs and Public Policy.
I look at health care from the perspective of someone who has been engaged in the policy and political debate over health care reform for more than thirty years, representing internists’ views on Capitol Hill.
For decades, we have seen Democratic and Republican presidents and congresses alike decide that health care reform is too hard. Always with excuses, of course:
“Sure, we need to fix health, but you can’t expect us to do it now.”
“It’s too big a pill to swallow . . . why can’t we just do smaller-scale reforms?”
And the corollary:
“We have other, more pressing issues.”
And the ones that blame voters:
“It is too big and complex for voters to understand.”
“Most voters have health insurance, so why change things?”
And the perennial refrain, whenever we get close to getting something done:
“Let’s just start over.”
Fifteen years ago, we heard many of these same things, when another Congress pulled the plug on another president’s plan to reform health care.
We are teetering on the edge of plunging into déjà vu all over again.
But there is a critical difference. The consequences of putting reform off for another five, ten or fifteen years are close to being unimaginable, but let’s try anyway.
Fast-forward to eight years from now. It is 2018, and a new President is in the White House.
The number of people enrolled in Medicare has increased to almost 60 million, but the ratio of taxpayers paying into the program to support each beneficiary is at its lowest point. Medicare’s hospital trust fund is out of money.
Unrestrained Medicare and Medicaid spending has led to out-of-control deficits and an explosion of public debt, leaving little money for other national priorities.
At the same time, rising premiums have put health care out of reach for many middle-class families. Small businesses are dropping coverage in droves. 60 million people have no health insurance coverage.
Because of a shortage of tens of thousands internists and family physicians, it takes many weeks—even months—to get appointments. And because of continued cuts in payments that do not cover their costs, most physicians are not accepting new Medicare and Medicaid patients.
What’s the new President to do? The President might have no choice but to propose huge payroll tax increases, cuts in Medicare benefits and eligibility, and reduced payments to physicians and hospitals.
Something will need to be done to reduce health care spending and make health insurance premiums affordable. But what?—federal money is scarce, and the options for covering people are so much more expensive than they used to be. Stringent controls over health care spending are needed, but anything that would make a big and immediate dent—like putting limits on services—would be fiercely resisted by patients and physicians alike.
This is the future that U.S. health care is facing—if we don’t reform health care now. But you don’t need to take my word for it—our report cites numerous respected sources that show this is the course we are on.
Unless we change course and enact comprehensive reforms to make health care sustainable and affordable.
Our recommendations are simple and straightforward.
Let’s take the bills passed by the House and Senate and make them even better. We shouldn’t toss them out and start from scratch. Instead, let’s take the best from each version, and modify elements—like special arrangements for some states and giving too much power to an unelected board—that have raised legitimate concerns.
The current bills would make affordable coverage available to most Americans. They would begin to increase the number of primary care physicians and reform payment and delivery systems to achieve better value. These policies should be preserved in a final bill.
In particular, our paper recommends the strongest possible measures from each bill to begin to reverse a catastrophic shortage of primary care physicians. We call for increased and mandated funding for programs to train more primary care physicians, creation of a new loan repayment program for specialties facing shortages, and increased Medicare and Medicaid primary care payments.
We also need to accelerate testing and adoption of the patient-centered medical home and to fund research on the comparative effectiveness of different treatments.
We understand the appeal of passing a series of smaller bills. The problem, though, is that small bills are likely to produce “Swiss Cheese” reforms that do not work in practice. History tells us that small, incremental reforms are not likely to put health care on a sustainable path. If they were, we wouldn’t be in the fix we are in today. The impact of smaller, stand-alone proposals should be evaluated based on a few simple questions:
How much do they do to reduce the number of uninsured and make health care more secure for those with insurance?
How much do they do to ensure a sufficient supply of primary care physicians and other specialties facing shortage?
How much do they do to make health care more affordable and sustainable?
Second, we believe that President Obama and Congress should strive to find bipartisan agreement on common ground and common sense reforms—but not in lieu of comprehensive reforms. For instance, we believe that there is strong bipartisan support for increasing the numbers of primary care physicians. And, as Dr. Stubbs noted, we believe that the President should specifically reach out to Republicans and Democrats alike to develop bipartisan proposals to reform the medical liability tort system.
Third, we believe that Congress should advance the goals of health care reform through the budget process. By increasing funding for primary care training programs, comparative effectiveness research, and health information technology, Congress can lay the groundwork for the comprehensive reform.
Fourth, Congress needs to stop the cycle of Medicare pay cuts caused by the Sustainable Growth Rate, once and for all. It needs to end the practice of enacting temporary stop-gap measures that kick the can to someone else to solve, driving up the cost in the process. Patients and physicians need stable, predictable and positive payments.
Finally, there is much that this administration can do through its executive powers to advance health care reform goals, even as the legislation makes its way through Congress. We urge the President to issue an executive order to require that all federal agencies, and health insurers doing business with the federal government, develop specific plans to support primary care with improved payments, research, training, recruitment, and adoption of innovative models like Patient-Centered Medical Home.
Just think about how much could be accomplished if every federal agency made it a goal to support and sustain primary care in the United States, and was held accountable for making measurable improvements.
Our written report provides more detail on the executive actions that the Obama administration should take to increase the numbers of primary care physicians, accelerate testing of innovative delivery reforms like the Patient-Centered Medical Home, and reduce the time that clinicians and patients must spend on administrative tasks.
In conclusion, ACP is under no illusion that overcoming the remaining political hurdles will be easy.
We recognize that the difficult and contentious political process has left many people disillusioned.
We believe that misinformation about the health care reform legislation has contributed to a poisonous atmosphere that has made consensus more difficult.
We acknowledge that advocates of health care reform have not been able to persuade many Americans that they will be better off.
We recognize that many Americans are concerned about the ability of Washington to deliver on its promises and keep spending under control.
We recognize that there are strong and legitimate philosophical differences among Democrats, Republicans and Independents on how best to reform the health care system.
We believe that neither political party has a monopoly on good ideas for reform of health care, but excessive partisanship has accentuated the differences rather than promoting common ground.
Nevertheless, we believe that President Obama and Congress must press forward on comprehensive reforms to expand coverage, provide patients with access to a primary care, and institute payment and delivery reforms to ensure the sustainability and affordability of U.S. health care.
As Dr. Stubbs said:
“The alternative is an unconscionable abdication of responsibility by our elected leaders to ensure that high quality health care remains available and affordable for American families today, tomorrow and for years to come.”
Dr. Stubbs and I would be pleased to answer your questions.
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