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The Declining State of the Nation's Health CareAnd 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
"It's too big a pill to swallow . . . why can't we just do
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
"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
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
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
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
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
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
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
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
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
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
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
We recognize that many Americans are concerned about the ability
of Washington to deliver on its promises and keep spending under
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
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.