Is it possible to find bipartisan common ground on improving the Affordable Care Act?
And can the United States have a serious conversion on how to conserve and allocate limited health care resources?
Conventional wisdom says no. Instead of working together to improve the ACA, both parties seem to be locked into a no-win battle over repeal. Discussion of conserving resources and controlling costs seems always to lead to unproductive charges and counter-charges about rationing.
But yesterday, in its annual State of the Nation’s Health Care report, the American College of Physicians challenged conventional wisdom.
ACP argued that common ground is possible on sustaining and improving the Affordable Care Act, including incorporating improvements usually associated with Republicans. ACP also expressed its belief that the country must confront the necessity of making hard decisions on conserving and allocating limited health care resources, but in a way that is in accord with distinctly American values.
I had the honor of joining ACP President Fred Ralston, MD, FACP, to present ACP’s recommendations at a press conference in Washington, D.C.
We made the case that the United States is facing an unprecedented health care crisis: more uninsured than ever before, the erosion of private employer-based coverage, more people on under-funded public safety net programs, a growing shortage of physicians in critical specialties including primary care, and rising costs that will bankrupt the country. We presented ACP’s firm belief that the Affordable Care Act has policies that are essential to addressing these challenges, and should not be repealed.
But we also argued that the law could be improved by giving states more options, earlier, to design their own systems to cover as many people and/or to enter into agreements to sell insurance across state lines; to replace the Medicare SGR formula with one that provides higher updates to all physicians and improved payment for primary care; and to reform the broken medical liability system—an issue traditionally associated with the GOP that President Obama said on Tuesday he is open to addressing. In addition to advocating for caps on non-economic damages, ACP urged Congress to fund a national pilot of health courts, a “no fault” model where claims would be heard by a judge with special training and access to independent medical advice.
We also released a major new ACP position paper, How Can Our Nation Conserve and Distribute Health Care Resources Effectively and Efficiently, which argues that the United States, like all countries, must address the fact of rising health care costs that threaten the economic health of the nation.
ACP believes that decisions on conserving and allocating resources, at the patient-physician level and societal level, should be informed by evidence of clinical effectiveness with consideration of cost. The paper makes a distinction between explicit medical rationing (as exists in many other countries) and making rational allocations decisions informed by evidence:
"We recognize that discussion of the most effective and appropriate ways to make such decisions, to the benefit of individual patients and the broader population, are undermined when the debate becomes polarized over whether or how care in the United States should be “rationed”—a term that is poorly understood, emotionally driven, and not conducive to reaching consensus. Achieving a national consensus on how best to use health care resources effectively, efficiently, and rationally should instead seek to distinguish between medical rationing, in which decision-makers determine which scarce medical resources are provided and who receives them, and rational medical decision-making, by which judicious choices are made among clinically effective alternatives. We emphasize that choosing among clinically effective alternatives based on medical evidence to provide clinically appropriate and effective care that maximizes value is not the same as rationing, which results in denial of care."
I am a realist, and I don’t expect that ACP’s recommendations will magically overcome the partisan divide on repeal of the ACA. Nor do I expect that everyone suddenly will join hands, sing kumbaya, and reach agreement on how to allocate limited health care resources, fairly and judiciously.
At some point, though, I hope it will become apparent to all sides that the ACA won’t be repealed, but that it can be improved. ACP’s recommendations can contribute to finding such bipartisan common ground.
And I hope that responsible people across the ideological spectrum will soon realize that the best way to avoid explicit medical rationing, as exists in many other countries, is to confront the issue now on what the United States can afford. But such decisions must be done through an open, transparent, and participatory process that empowers people to make decisions based on evidence, instead of imposing limits on them.
Today’s questions: What is your reaction to ACP’s efforts to urge the political parties to seek common ground on improving the ACA? And to our proposal to start a conversation on conserving and allocating resources based on evidence?