Friday, August 23, 2013

Guess what? Congress has already “defunded” parts of Obamacare . . .

Or, more accurately, it has declined to fund parts of it.  Unfortunately, the parts it hasn’t funded include several key programs to train more primary care physicians and provide resources to those already in practice.

To be absolutely clear, the current drive by the Heritage Foundation and some members of the House and Senate to defund the entire ACA will go nowhere.   There is absolutely no chance, nada, that President Obama would sign into law a spending bill that defunds his signature first term achievement, even if it means allowing the government to shutdown on October 1.  (Read Eugene Robinson’s column in today’s  Washington Post for a good explanation of why defunding Obamacare is a fantasy). 

As we (current and former) New Yorkers, might say, fugetaboutit!

But what is being overlooked in the current defunding debate is the damage that has already been done by Congress’ refusal to fund important parts of Obamacare.  I don’t mean the law’s coverage expansions—they are all funded and will go live starting October 1 (state marketplaces/exchanges) and January 1, 2015 (tax credit subsidies, federal dollars to expand Medicaid).  But there is a long list of Obamacare programs that haven’t been funded, or received much less funding than originally anticipated, undermining their effectiveness.   Most troubling are the underfunding/defunding of programs to address the shortage of primary care physicians. 

On March 24, 2010, the Congressional Research Service issued a report to Congress on the public health, workforce and quality-related provisions in Obamacare.  It is an impressive list of programs authorized by the ACA, but authorization doesn’t necessarily mean funding.  The congressional appropriations process decides which “authorized” programs will be funded, and by how much, and it is here where much damage has been done. I haven’t had the time yet to go through the CRS report in detail, to see how many of the programs listed were actually funded, as opposed to those that have received zero dollars and therefore exist only on paper.  But the following two stand out because I know for a fact that they have not received  a dime from Congress, yet they could have done a lot of good:

National Workforce Commission: An ACP fact sheet describes the intended functions of the 15-member expert commission, which included, “Analyze, and make recommendations for, eliminating the barriers to entering and staying in primary care, including provider compensation.”  It also would provide recommendations to Congress and the Administration on national health workforce priorities, goals, and policies, review current and projected health care workforce supply and demand (in consultation with relevant Federal, State and local entities), review implementation/performance of a separate State Health Care Workforce Development Grant Program also created by the ACA, assess education and training activities to determine whether demand for health care workers is being met,  and study effective mechanisms for financing education and training for careers in health care.  It would have made annual reports to Congress and the administration on its recommendations.  John McDonough, who was a key Democratic staffer on Capitol Hill at the time that Obamacare was enacted, recalls that, “no other title of the law received such broad support and so little controversy” as did the section that authorized the National Workforce Commission.  He notes that the Commission members have been appointed but, ”the Committee has been unable to hold its first meeting...As Robert Pear [reported in the February 25, 2013 edition] of the New York Times, the Commission is legally prohibited from convening -- and members are legally prohibited from communicating with each other -- because the Republican-controlled House of Representatives refuses to release the $2 million or so necessary to fund the commission's operations. Why? Because the Commission was established in the ACA, (aka: ObamaCare) and Republicans in Congress are unwilling to support anything that is part of ObamaCare, even if everyone agrees that workforce shortages represent an urgent national, state, county and local need.”

So let’s get this straight: the federal government spends, through Medicare, more than $9 billion each year on graduate medical education.  The United States is facing a shortage of more than 40,000 primary care physicians for adults by the end of the decade.  People in many parts of the country are already underserved.  Obamacare and an aging population will increase the demand for primary care. Going without a doctor shouldn’t be a partisan issue: getting sick isn’t a function of one’s political leanings.  Yet Congress can’t find $2 million out of its $3.5 trillion budget to allow a group of experts to help it figure out how to spend taxpayers’ dollars more wisely and effectively to ensure that we have enough primary care physicians (and health professionals in other fields facing shortages).  Just because the National Workforce Commission is authorized by Obamacare.

Primary Care Extension Program: this program, also authorized by Obamacare, would have funded local primary care extension agencies to support and educate primary care clinicians about preventive medicine, health promotion, chronic disease management, mental health services and evidence-based therapies.  The program also would have provided funding for local community health workers to provide direct assistance to primary care physicians in implementing quality improvement programs or system redesign that incorporates the principles of the Patient-Centered Medical Home (PCMH)  (Congressional Research Service).   The Primary Care Extension program was specifically intended to provide resources to primary care physicians in smaller practices to help them make the changes needed to successfully become PCMHs or participate in other quality improvement and system redesign initiatives, without them having to bear all of the costs themselves.  The ACA provision was based on a proposal by Kevin Grumbach, MD and James Mold, MD, published by the Journal of the American Medical Association, on June 24, 2009.  The authors explained that:

 “New investment in primary care is necessary but not sufficient to revitalize primary care unless combined with a strategy for disseminating and implementing innovations and best practices. Acquiring an electronic health record (EHR) will not create a highly functioning medical home unless it can be used to create functional patient registries. Receiving enhanced payments for care coordination without a workable plan for hiring and training health coaches for patient self-management leaves a gap between expectations and reality. Large, organized delivery systems such as Geisenger, Kaiser Permanente, and the Veterans Administration have the institutional wherewithal and economies of scale to implement practice redesign in a systematic and successful manner. However, two-thirds of office-based physicians work in practices of 4 or fewer physicians. These clinicians often have little or no technical assistance to deploy and maintain new practice improvements like EHRs . . .  A nationwide Primary Care Cooperative Extension Service, modeled after the US Department of Agriculture's Cooperative State Research, Education, and Extension Service (Cooperative Extension), which so successfully accelerated farm transformation, should be created. County-based health extension organizations would support primary care clinicians in the same manner that the agricultural model assists family farmers, providing infrastructure for local learning communities and practice transformation.”

But once again, even though there is bipartisan support for helping primary care physicians organize their practices as PCMHs, and even though there is bipartisan recognition that this is particularly challenging for primary care physicians in smaller practices, Congress hasn’t funded this innovative program to help smaller primary care practices make the transition, because it is part of Obamacare, and you know, the House of Representatives won’t fund any part of Obamacare if they can help it.

There are many, many more Obamacare programs that haven’t received funding from Congress, including many dozens of programs intended to support primary care, because of the unrelenting efforts by some conservatives to kill and defund the entire law, even the parts that, in a less polarized and partisan world, would have bipartisan support.  Like getting expert advice on how to spend federal dollars more wisely to ensure that we have enough primary care physicians.  Or helping primary care physicians in smaller practices survive. 

The “defund Obamacare” camp will not be able to block funding for the Obamacare coverage expansions that will go into effect this fall and next year.  But by “defunding” other parts of Obamacare, they are making it harder for the patients, who will get coverage, to find a doctor. 

Today’s questions: What do you think of the effort to defund Obamacare, all of it, even though there is almost no plausible scenario where  it can succeed, and even if it leads to a government shutdown?  What do you think will be the impact of Congress having already “defunded” programs to help increase the number of primary care physicians and provide help to those already in practice?


ryanjo said...

I think this type of brinkmanship is innate in our political system. It has been more prominent in the past 6 years because we have an idealogue as President. The Tea Partiers on the other side of the aisle were elected to counter the Democrat majority's unwillingness to compromise during his first 2 years in office, so why should they play along?

It is disheartening that the decision by AMA & ACP to support a political solution for healthcare restructuring throws small practice physicians, who carry half of primary care patients, under the bus. Apparently our medical leadership has decided this won't be disruptive at all. They work hard trying to convince their membership that this is good for us and our patients. Maybe somebody should talk to our patients. They aren't comforted.

Harrison said...

Small practice specialists have been just fine with throwing small practice primary care physicians under the bus for decades.

Without Obamacare it would be a guarantee that Primary Care practice by physicians in any independent setting would die.
They would be dependent on hospital systems and they in turn are dependent on procedures done by procedural specialists.

Procedural specialists are terribly threatened by anything that looks at outcomes and effectiveness.
They are backed by the medical equipment manufacturers, who also stand to gain by more expensive updates, and they don't want to prove much more than safety and convenience as reasons to justify their innovations.

If the Tea Party has a meaningful alternative to this escalation of costs for inefficiency, then please suggest it.

Obamacare is a start.
It unfortunately empowers insurers.
They will have more covered lives and more people.

But they will have incentives to move us all towards evidence based care that focuses on good outcomes.

Win Win isn't going to happen.
It hasn't happened for decades.
The only change is that there is a slightly greater risk to those who have been winning up until now.

I read a lot from the right and it is increasingly more frantic about the subject of repeal.
That can only be because 2014 is approaching.
And with it the risk that the public might start to like some of this law.
Premium prices are expected to fall in places where the exchanges are functioning.
Administrations that opposed the exchanges will be in some jeopardy of losing elections when that becomes clear.

And it is hard to see a Republican candidate winning nationally in 2016.


ryanjo said...

All analyses by health system economists & policymakers, including the well-known report in the Annals a few years ago by the White House insiders, predicts that ACA will annihilate small primary care practices. My local area primary care practices are rapidly become hospital affiliates or employees. The only winner will be the hospitals and other large corporations that can own all the pieces and successfully "game the system". Patients and their physician advocates always lose under this type of top down control. No doctor can serve two masters.

As far as reducing premiums, all indications are that the only reduction of premiums will be by government subsidies. Everyone with private insurance is already seeing and will see either a minor or major increase.

PCP said...

Looks like Harrison and Ryanjo are both in agreement that solo private practice days for PCPs are over.
Their only disagreement is in what that means for patients, the system and formthe profession.
ACP, you have won your battle to turn the profession you represent into indentured servitude.