Just about everyone in Washington knows that the Medicare SGR formula is about to cut payments to physicians by 21% on April 1, unless Congress overrules it. How many know, though, that primary care physicians are also facing a scheduled Medicare cut of 10% on January 1, 2016, unless Congress overrules it, which would be in addition to the SGR cut? Not too many, I suspect.
If Congress allows Medicare primary care payments to be cut on January 1, it would be the second consecutive year when federal payments to primary care physicians—and only primary care physicians—would be cut by double-digits. On the first of this year, Medicaid payments to primary care doctors were cut in most states by an average of 40%, because Congress failed to reauthorize a federally-funded program, called the Medicaid Primary Care Pay Parity program that, in 2013 and 2014, raised Medicaid payments for office visits, vaccines and other primary care services to no less than the applicable Medicare rates.
I call the potential combined impact of these cuts the primary care cliff: scheduled (and in the case of Medicaid, actual) cuts in federal payments to primary care physicians being allowed to go into effect because of Congress’s inaction.
Oh, and there is another primary care program that could go off the cliff. The National Health Service Corps (NHSC) provides scholarships and loan forgiveness to enable primary care physicians to be trained to serve underserved communities. The NHSC currently has a field-strength of over 9,000 clinicians and serves almost 10 million patients in underserved communities at more than 15,000 sites. Yet without dedicated funding by Congress for the new federal fiscal year that begins on October 1, the NHSC will have to cease its operations.
How did we end up with a primary care cliff?
Well, Medicaid Primary Care Pay Parity and the Medicare Primary Care Incentive Program were both created by the Affordable Care Act, aka Obamacare. Five years ago, Congress understood that if health insurance coverage was going to be expanded to tens of millions of Americans, then steps also needed to be taken to address the growing shortage of primary care physicians. It reasoned, correctly, that low Medicare and Medicaid payments were creating powerful disincentives for physicians to enter and remain in primary care, and for Medicaid, creating powerful disincentives for physicians to see patients enrolled in the program. This was a point that ACP continually pressed in our advocacy leading up to enactment of the ACA. While Congress clearly didn’t do enough in the ACA to address the undervaluation of primary care, the decision to raise primary care Medicare payments by 10%, and to raise Medicaid payments to no less than the Medicare rates, were steps in the right direction.
But resistance in Congress to the ACA’s cost caused Congress to put a time limit on these two programs. The Medicaid Primary Care Parity Program was funded and authorized for only two years, 2013 and 2014. The Medicare Primary Care Incentive Program was funded and authorized for five years, 2011 through 2015. Although ACP wanted both programs to get permanent funding, Congress decided that by putting a time limit on them, it would cause the Congressional Budget Office to come in with a lower “score” (cost estimate) on them, and therefore a lower “score” on the overall cost of the ACA, than if they were left permanent and open-ended.
Now, let’s fast forward to 2014. ACP repeatedly pressed Congress to reauthorize the Medicaid Primary Care Pay Parity Program. We helped persuade two Democratic Senators, Senators Sherrod Brown (D-OH) and Patty Murray (D-WA), to introduce legislation to continue it. A House version of the same bill was introduced by Representative Kathy Castor (D-FL). What we were unable to do was persuade any Republicans to sign on, and without Republican support—especially in the Republican controlled House—the legislation could go nowhere.
The reasons Republicans wouldn’t sign on were varied, but were mostly due to the fact that since Medicaid Primary Care Pay Parity was created by Obamacare, which they loathe and vowed to repeal, they couldn’t see their way to supporting a program created by it. Plus because many of them believe the Medicaid program is fundamentally flawed, they couldn’t see putting federal dollars to prop up its reimbursements to primary care physicians.
It is too early to tell how Republicans this year will feel about continuing the Medicare Primary Care Incentive Program. We know it won’t be an easy pitch to persuade them to continue it, because it too was created by Obamacare. But Medicare is far more popular with members of Congress, Republicans and Democrats alike, than Medicaid. And there are many Republican voters—patients and their physicians —who stand to lose if the Medicare Primary Care Incentive Program is allowed to expire at the end of this year.
The National Health Service Corps received a huge infusion of federal dollars from Obamacare, but it pre-dates it by decades and has long had bipartisan support. The NHSC website notes that “The NHSC was created in response to the health care crisis that emerged in the United States in the 1950s and 1960s. Older physicians were retiring and young doctors started to choose specialization over general practice, leaving many areas of the country without medical services. . . Since 1972, the NHSC has connected 45,000 primary health care practitioners to communities with limited access to primary care. Currently, 9,200 NHSC members provide care to more than 9.7 million people in the U.S., regardless of their ability to pay.” The prospects for this Congress then to agree on a bipartisan basis to continue the program are pretty good, especially since it was not created by Obamacare, but hardly a given.
So what is ACP doing about the primary care cliff? Yesterday, we released a new report, called Healthcare and the 114th Congress: A Dynamic Guide to the Top Issues Affecting Internal Medicine Specialists and Their Patients, which provides short—two page—explanations of six issues before Congress that will have the greatest impact on internists, and ACP’s recommendations on each. In the top six were continuing the Medicare Primary Care Incentive Program, restoring the Medicaid Primary Care Pay Parity Program, and ensuring funding for vital health care programs, including the National Health Service Corps. Repealing the SGR, ensuring sufficient funding for Graduate Medical Education, and continuing premium subsidies established by the Affordable Care Act were our other three top priorities. We also released a three page summary of our recommendations on all six.
We recognize that getting Congress to agree with us on won’t be easy, especially in today’s hyper-polarized political environment. But they represent the issues that we will be fighting for, despite the obstacles, because they are so important to our members and their patients. We will need your help to explain to members of Congress, Republicans and Democrats, that driving primary care off the cliff is bad for patients, no matter what they might think of Obamacare.
Today’s question: What would you tell Congress about the primary care cliff?