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Health Care Coverage, Capacity and Cost: What Does the Future
A Report from America's Internists on the State of America's Health
J. Fred Ralston Jr., MD, FACP
American College of Physicians
Thank you for joining us for this report from America's
internists on the State of the Nation's Health Care.
I have had the privilege of serving as president of the American
College of Physicians for the past year. One of the greatest parts
of my presidency is how it has allowed me to be active in advocacy
on health-care issues. I've combined my political science
background with the real-world perspective of a physician in
full-time clinical practice.
Since 1983, I have been in the practice of general internal
medicine in Fayetteville, Tennessee. My group -- Fayetteville
Medical Associates -- includes internists, family physicians,
pediatricians and a nurse practitioner. The group traces its roots
to 1909 and serves a rural county of 30,000 near Huntsville,
Clearly, a highly-partisan and polarized debate over health care
reform legislation regrettably has taken the country's "eye off the
ball"-from the continued urgency of implementing reforms to making
health insurance coverage more affordable, available and secure; to
ensuring a sufficient supply of primary care physicians and other
specialties facing shortages; and to reforming payment and delivery
systems to achieve better value.
Today, I have some good news and bad news to report about the
state of the nation's health care.
The bad news is that the United States is facing an
unprecedented crisis in affordable health insurance coverage. We
have more uninsured people than ever before. We still are facing a
crisis in access to primary care. Health care costs are increasing
at rate that the country-and individual families-can't afford.
The good news is that the Affordable Care Act has essential
policies to begin to address these challenges, but only if Congress
allows them to take root and grow.
Describes the challenges the U.S. faces in
providing affordable health insurance coverage for all, ensuring
that the system has the capacity to meet the growing demand for
health care, and controlling costs;
Discusses how the ACA begins to address these challenges and the
necessity of preserving, building upon, and improving its
essential policies to expand coverage, increase health
care capacity, and address rising costs;
Recommends improvements in the ACA, including
changes that have the potential of attracting
bipartisan support; and
Presents the recommendations of the American College of
Physicians (ACP) for building upon the ACA's reforms to
create a better health care system for all Americans, including
release today of a new ACP position paper on conserving and
allocating limited health care resources in accord with distinctly
I see patients every day struggling to manage health care.
I have a patient with a limited education who struggles to make
ends meet Like so many others during the Great Recession, he lost
his job in the auto manufacturing support industry for a year. I
treated him for free during that time, as I knew his health would
deteriorate without proper medical attention. I was pleased when he
was rehired but was distressed to receive a letter asking if I had
treated him for similar conditions over the past year - clearly an
attempt to exclude or limit coverage due to pre-existing
conditions. This is an example of how our health care "system"
doesn't work for many hard working Americans trying to make ends
He is one of the more than 129 million Americans with
pre-existing conditions who will benefit from the ACA's prohibition
on insurance companies excluding or rescinding coverage or charging
excessive rates to people with pre-existing conditions.
And starting in 2014, if my patient should be unfortunate enough
to lose his job again because of another economic downturn, at
least he'll know that he'll be able to get affordable coverage
because of the ACA.
ACP views necessary health reform not from a partisan or
ideological perspective, but from the standpoint of what the
evidence tells us will be the most effective course of action. Lack
of health insurance can be a matter of life and death. Studies show
that being without health insurance leads to tens of thousands
of premature deaths annually and unnecessary suffering.
Instead of turning away from the ACA's promise of ensuring
access to affordable health insurance to nearly all Americans, ACP
believes that Congress should seek bipartisan common ground on
making improvements to it, including giving states more freedom
earlier to implement the coverage expansions in a way that best
meets their own needs.
Ensuring that all Americans have affordable health insurance
coverage is essential, but insurance coverage alone does not
guarantee access to care in the absence of well-trained
physicians and other clinicians to provide the care that they
The United States is facing a growing shortage of physicians in
key specialties, most notably in general internal medicine
and family medicine-the specialties that provide primary care to
most adult and adolescent patients.
A recent study projects that there will be a shortage of up to
44,000 primary care physicians for adults, even before the
increased demand for health care services that will result from
near universal coverage is taken into account.
A new report details the potential impact of many of the ACA's
policies to begin to address the crisis in primary care. Yet even
with such policies, the U.S. will likely continue to face a
shortage of primary care physicians for adults, as well as
shortages in other critical physician specialties, but this
shortage will be much more severe if the ACA's policies to
ensure adequate workforce capacity are under-funded or
Finally, I want to talk about the biggest challenge facing our
health care system: costs that are rising faster than we can
afford. The ACA has important programs to begin to bend the
cost curve, including funding for comparative effectiveness
research and new payment and delivery models to align incentives to
clinicians with value. These need to be supported and sustained by
But the medical profession must also do its part. Several months
ago, ACP launched the High-Value, Cost-Conscious Care
Initiative, a broad program that connects two important
priorities for ACP: helping our physicians to provide the best
possible care to their patients, and simultaneously reducing
unnecessary costs to the health care system.
This initiative will provide physicians and patients with
evidence-based recommendations for specific interventions for a
variety of clinical problems. The Initiative will assess
benefits, harms, and costs of diagnostic tests and treatments for
various diseases to determine whether they provide good value -
medical benefits that are commensurate with their costs and
outweigh any harm. The February 1, 2011 issue of the Annals of
Internal Medicine, ACP's peer-reviewed, flagship journal, will
publish two important papers related to the High-Value,
Cost-Conscious Care Initiative.
But if the polarized health care debate has shown us one thing,
it is that the public itself needs to be engaged in decisions on
how best to conserve limited health care resources. We physicians
can't do it alone, and the public won't accept cost controls that
are imposed upon them by government, insurance companies, or
employers. Instead, all of us-physicians, our patients,
government, insurers, employers, and other stakeholders-need to
have a frank discussion on how to conserve and distribute limited
health care resources, effectively and efficiently, and in a way
that is in accord with distinctly American values.
Therefore… today, ACP releases a new position paper,
How Can Our Nation Conserve and Distribute Health Care Resources
Effectively and Efficiently?
The paper offers more than a dozen principles for engaging the
public in a process that we hope will lead to consensus on
conserving and allocating resources, based on the best evidence of
value. To ACP's knowledge, this is the first time that a major
physician membership society has called for a national consensus on
conserving and allocating health care resources and proposed a
framework on how to make such decisions.
To be clear, ACP is not proposing that care be rationed.
Rationing is a term that is poorly understood, emotionally-driven,
and not conducive to reaching consensus. It conjures up images of
shortages, delays in obtaining treatment, long waiting lines, and
government bureaucrats coming between patients and their
But there is a difference between medical rationing, in which
decisions are made about the allocation of scarce medical resources
and who receives them, and rational medical decision-making,
by which judicious choices are made among clinically effective
I look at rational use of resources on a personal level as
obtaining and using the proper information on diagnostic and
treatment options that I would want used on my family. If a test or
treatment is shown to be superior to other options on the basis of
safety, outcomes, and/or cost it is what I would want my mother, my
wife or my sons to receive. We need unbiased research to make sure
that physicians and patients have access to the best treatment
Every country makes decisions on how to allocate available
health care resources, but their approaches vary widely, reflecting
the different political and cultural conditions in each country.
The United States limits access to services based on access to
affordable health insurance coverage and insurance company
decisions on covered benefits and cost-sharing. Socio-economic and
racial and ethnic characteristics of the population being served,
the availability of physicians and health care facilities, and
other factors clearly impact the access to care in the U.S.
Yet the U.S. has largely failed to address the reality that
health care spending is increasing at a rate the country can't
afford. This is a societal issue that transcends medical care
itself-how much should we as a society spend using public funds on
health care versus education, the environment, or the defense of
Democratically elected countries have a responsibility to
develop ways to determine the allocation of public resources that
have broad public support; such decisions in the U.S. cannot and
must not be "imposed" on the population without the consent of
the people. This means that:
At the patient encounter level, physicians-in consultation with
patients-- have a responsibility to use health care resources
wisely, based on evidence of safety and effectiveness, the
particular needs and circumstances of the patient, and with
consideration of cost.
At the societal level, allocation decisions should be informed
by evidence on the value of different interventions, be in accord
with societal values, and reflect moral, ethical, cultural, and
professional standards, and developed with broad public input.
ACP's paper proposes specific principles for achieving such a
consensus on conserving and distributing health care at both the
patient encounter and societal levels.
We believe that engaging the public in such a consensus can help
eliminate much of the $700 billion of health care spending
per year, 5 percent of the nation's GDP, which studies
suggest are wasted on tests and procedures that do not improve
health outcomes. We also believe that eliminating wasteful
spending may be the only way that the United States can avoid the
explicit medical rationing that exists in other countries.
We know it won't be easy. We know we don't have all of the
answers on how to initiate such a discussion. We offer our paper,
though, in the fervent hope that it will lead to a non-partisan
dialogue on how best to ensure that spending on health care is
sustainable and doesn't bankrupt our country.
Now, I am pleased to introduce Bob Doherty, the senior vice
president of ACP's division of government affairs and public
policy. He will describe the current political environment and
provide more information on ACP's policy recommendations for
finding common ground on building and improving upon the essential
policies in the Affordable Care Act.