State of the Nation’s Health Care 2011
Health Care Coverage, Capacity and Cost: What Does the Future Hold?
A Report from America’s Internists on the State of America’s Health Care
Senior Vice President, Governmental Affairs and Public Policy
American College of Physicians
I am pleased to join Dr. Ralston in presenting our ideas for common ground solutions to the three biggest challenges facing American health care, which are to ensure that:
Everyone has affordable coverage;
Everyone has access to a personal physician; and
Rising health costs do not bankrupt the country, employers and American families.
We believe that the Affordable Care Act (ACA) has policies that are absolutely essential to address these challenges. It must not be repealed.
But no legislation is perfect. President Obama, in his State of the Union address to Congress, said he is willing to consider “ideas about how to improve this law by making care better or more affordable.”
Mr. President, we agree with you, and hope that both political parties will work together to make the law better.
Yet conventional wisdom tells us that unrelenting political conflict over the Affordable Care Act appears to be the order of the day.
Republicans are committed to the ACA’s repeal and Democrats are committed to keeping it intact.
The simple fact, though, is that neither side can win this fight. The law won’t go away, as most Republicans hope, but restrictions on funding and enforcement could undermine its effectiveness, as many Democrats fear.
We could end up with a law that remains on the books— along with all of its controversial mandates, like the requirement that people buy insurance—but without the funding needed for it to work well for American families. For instance:
The law might prohibit insurance companies from excluding or over-charging people with pre-existing conditions, but many Americans could still be turned away if Congress doesn’t give federal agencies the money needed to enforce the rules.
The law might guarantee access to coverage, but if Congress doesn’t fund the ACA’s programs to train and retain more primary care physicians, patients will wait longer for appointments, leading to delays in getting needed treatment, poorer outcomes, and higher costs.
The American College of Physicians (ACP) firmly believes that the United States must not go back on expanding coverage, training and retaining primary care physicians, and beginning to “bend the cost curve.” Our report, which is included in your press packet and is online, identifies many essential programs established by the ACA to address such challenges.
Keeping these programs on the books is not enough; they also need to be funded. The law’s “discretionary” programs—meaning that they are subject to annual appropriations—are particularly vulnerable to cuts, given the pressure to cut federal spending on non-entitlement programs:
Programs like the Title VII health professions training programs, which have proven track records in getting more primary care physicians trained and working in underserved areas.
Such programs need to be funded at no lower than the levels authorized by the ACA.
Otherwise, the country will spend much more because of a growing shortage of primary care physicians. Research tells us that having an adequate number of primary care physicians in a community is positively associated with better outcomes and lower costs.
Many “mandatory” programs might also be vulnerable to Congress placing restrictions on effective enforcement by federal agencies, such as:
Programs to expand coverage, including tax credits for small businesses and families and money to states to set up health exchanges and enroll more people in Medicaid.
Higher Medicare and Medicaid payments to primary care physicians.
Comparative effectiveness research to inform clinical decision-making.
In addition, financial incentives for physicians to meaningful use certified electronic health records to improve patient outcomes could be at risk. Such incentives are included in the American Recovery and Reinvestment Act (ARRA) and could be considered to be among the unspent “stimulus” dollars that House Republicans have pledged to eliminate.
The threat that Congress might cancel the incentive program will discourage physicians from moving forward on health information technology investments, and could pull the rug out on those who have already invested tens of thousands of dollars in the expectation that they will qualify for the incentive payments.
Yet many of the specific programs that appear to be vulnerable have had a long legacy of bipartisan support, which we hope will carry over into the 112th Congress. The goal of everyone having access to electronic health records within 10 years was first set by a Republican president, George W. Bush, in his 2005 State of the Union speech to Congress. Ever since then, Congress has worked together on a bipartisan basis to advance this goal.
Republicans and Democrats alike have also supported reforms to support the value of primary care. Legislation to authorize Medicare pilots of Patient-Centered Medical Homes, for instance, originated in the GOP-led 109th Congress.
We know that bipartisan solutions remain possible, if we can move beyond arguing about repeal, to seeking common ground to build and improve upon the Affordable Care Act.
Let me suggest five such areas:
First, Congress and the White House should seek common ground on giving states more options sooner.
Today, ACP is pleased to announce its support for the Empowering States to Innovate Act, introduced in the 111th Congress by Democrat Ron Wyden and Republican Scott Brown. This bill would give states the option to seek waivers, three years earlier than now permitted by the ACA, to design their own programs to expand coverage, free of many of the law’s mandates, as long as they could provide affordable and sufficient cover to at least as many people.
We also call for modifying the ACA to allow states to enter in an agreement for insurance to be sold across state lines, two years earlier than the current effective date of 2016.
Second, Congress and the White House should seek common ground on replacing Medicare’s sustainable growth rate (SGR) formula with a new framework.
This new framework should ensure stable and positive updates for all physicians, provide additional increases for undervalued primary care services, protect payments for primary care from being reduced due to volume increase in other categories of services, and create incentives for physician practices to become Patient-Centered Medical Homes.
Third, Congress and the White House should seek common ground solutions to reduce health care costs.
They should start by agreeing to support the programs authorized by the ACA that have the greatest potential to lower costs and improve outcomes.
It makes no sense, for instance, for fiscal conservatives to want to eliminate funding for comparative effectiveness research to help patients and their doctors make better choices based on evidence, or to reduce funding for Medicare and Medicaid pilots to align incentives to clinicians with value.
Fourth, Congress and the White House should seek common ground on effective approaches to reduce the costs of defensive medicine.
We are encouraged that President Obama, in his State of the Union remarks, promised to “look at other ideas to bring down costs, including one that Republicans suggested last year -- medical malpractice reform to rein in frivolous lawsuits.”
Mr. President, we agree that more needs to be done to fix a broken medical liability system:
ACP is one of over 100 physician membership organizations that have endorsed H.R. 5, the “Help Efficient, Accessible, Low-cost, Timely Healthcare (HEALTH) Act of 2011,” introduced by Rep. Phil Gingrey. This bill includes caps on non-economic damages and other reforms that have been proven to reduce the costs of defensive medicine.
We recognize, though, that caps aren’t the only or entire solution. Today, ACP calls on Congress to enact legislation to allow for pilot-testing of health courts on a national scale.
Health courts are a no-fault system that would have cases heard by specially trained judges, who would have access to independent medical experts. The judges would be empowered to rule on the merits of claims and to authorize awards commensurate to the actual damages incurred.
Fifth, as Dr. Ralston has so eloquently described, both political parties must confront the reality that we can’t spend unlimited amounts of money on health care.
We need to have a national conversation on how to conserve and share health care resources effectively, efficiently, judiciously, and fairly, based on the evidence of their clinical effectiveness and value, and in accord with distinctive American values including individualism.
To start this conversation, ACP proposes key elements that should be considered in making such decisions, including empowering people to make decisions based on the best evidence of value and ensuring broad input from the public and all affected stakeholders.
We understand the challenges involved in reaching consensus on conserving and allocating health care resources, but beginning this conversation now can help the United States avoid the explicit limits on care that exist in other countries.
Let’s now return to the politics. As I said at the beginning, the conventional wisdom is that we can expect nothing more from Congress over the next two more years other than unrelenting conflict over repeal of the Affordable Care Act.
The conventional wisdom might be right, but we must insist on something better.
The problems facing American health care are too great to have two more years of political wrangling that will lead to gridlock, or even worse, an under-funded and poorly implemented Affordable Care Act.
Former Senate Majority Leader Bill Frist, a Tennessee Republican and heart surgeon, recently said this:
“The reality is that the law will remain largely intact. . . That being the case, it is important that it be made to work as effectively as possible . . . there are lots of things that can be fixed or modified by working together.”
Dr. Frist, we agree with you.
In today’s State of the Nation’s Health Care report, ACP proposes specific ways to build and improve upon the ACA: give states more options, reduce the costs of defensive medicine, replace the Medicare SGR formula, improve payments for primary care services, and initiate a broad national discussion on conserving health care resources.
We hope others will join us in challenging our elected leaders to find common ground solutions to sustain, build and improve upon the ACA’s essential policies on coverage, capacity and costs, considering ideas from across the political spectrum and from America’s internal medicine physicians.
Dr. Ralston and I would be pleased to answer your questions.
ACP Policies and Recommendations
This library is a collection of ACP's Clinical Guidelines, Ethical Guidelines, Policy Statements, and copies of testimony and letters to government and non-government officials.
The ACP Advocate Blog
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The ACP Advocate Newsletter
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