It’s health care, stupid

This seems to be the big take-home message from voters in the mid-term election held yesterday, which bodes well for preserving gains from the Affordable Care Act and expanding coverage.   Health care was the number 1 issue for voters according to several exit polls, beating out immigration, the economy, and gun violence, among others, with voters strongly favoring Democrats as the party more likely to protect patients with pre-existing conditions.  Preserving the ACA’s protections for pre-existing conditions arguably may have been the single greatest contributor to Democrats taking control of the House of Representatives from Republicans, gaining at least 30 seats. 

Yet Republicans not only kept control of the Senate, they also expanded the number of Senate seats they control, adding at least 3 seats to be held by members with strongly conservative views. This raises questions about how much of the electorate’s desire for Congress to act to make health care more affordable to them and their families will translate into action in Congress; preserving existing patient protections may be the most likely outcome.

The story at the state level is very different: more states seem poised to expand Medicaid coverage; yet on other health care issues, like women’s access to reproductive services or reducing gun violence, the prospects at the state level are more mixed.

Here’s my take on five health care issues likely to be affected by the mid-term election results:

1.  Obamacare repeal and replace is dead. The Democratic-controlled House of Representatives will not allow legislation to advance to repeal, or repeal and replace, the Affordable Care Act. 

Except . . .Congress will have to do something to preserve protections for preexisting conditions, if the courts ultimately rule in favor of a case brought by 20 GOP-led states and supported by the Trump administration that seeks to have the ACA’s protections for pre-existing conditions ruled unconstitutional.  A decision by a conservative Texas judge is imminent and should he rule for the plaintiffs, as many expect, it will assuredly be appealed to the higher courts; it may be up to the Supreme Court to ultimately decide.  Stripping pre-existing condition protections via a court decry will be hugely unpopular with the electorate, and almost all of those elected yesterday promised to protect them (even when their own voting records suggest otherwise). However, it’s by no means certain that a Democratic House, Republican Senate, and President Trump could agree on a path forward to reinstate them.  The best outcome would be for the courts to find that the case has no merit and rule against the plaintiffs.

And . . . while there may be interest in both political parties to advance bills to make the ACA more affordable for those who are not eligible for premium subsidies because they earn too much to qualify, it is hard to see a path forward that could bridge the ideological divide between Republicans and Democrats.  House Democrats will also try to advance bills to overturn the administration’s decisions to allow sale of short-term plans that do not cover essential benefits, yet such bills likely would die in the Senate, or face a veto from the president.  States that have elected Democrats as governors and to the statehouses may pass legislation on their own to ban or regulate sale of short-term plans.

2.  More low-income people will gain coverage from Medicaid expansion, upwards of half a million of them.  Voters approved Medicaid expansion via referenda in three GOP-leaning states: Idaho, Nebraska, and Utah. The election results in three other states, Maine, Wisconsin, and Kansas, also bode well for expansion.  Montana voters, however, voted down a referendum to continue to fund their version of Medicaid expansion via higher tobacco taxes, potentially placing coverage for their residents at risk.  Republicans elected or re-elected to the governorships in other states are unlikely to expand Medicaid, and/or will seek to include work requirements that may make it more difficult for people to qualify.

3.  Prospects for policies to address the high cost of prescription drugs may advance at both the state and federal levels.  In his initial remarks today on the midterm elections, President Trump suggested that common-ground could be found with Congress and the Democrats on lowering the cost of prescription drugs. Many Democrats newly elected to the governorships and state legislative seats favor policies to require transparency in drug pricing.

4.  Common-sense policies to reduce gun violence may be advanced in additional states, as voters elected candidates to governorships and legislatures who favor such policies; yet in other states, voters elected or re-elected candidates opposed to such policies.  Voters in Washington state approved a referendum to advance restrictions on firearms. NBC’s exit poll found that 60% of those who casted votes favored stricter gun control policies, including 46 percent of gun owners compared to 76% of those who don’t own firearms; just one-in-ten ranked it as the most important issue facing the country. Democrats are likely to advance gun violence policies in the House, yet it is unlikely that a more conservative Senate and the Trump administration will accept them.  On the other hand, the House will almost certainly reject concealed carry reciprocity, should it be taken up next year by the Senate.  (In the current Congress, such legislation passed the GOP-controlled House, but was not taken up by Senate).

5.  It’s a mixed bag for women’s health.  The House of Representative will not advance or accept legislation to defund Planned Parenthood and other women’s health clinics.  It may try to advance bills to overturn the administration’s efforts to allow broad “conscience exemptions” to contraception coverage, yet it’s hard to imagine those being accepted by the Senate.  With more states under partial or complete Democratic control (governors and statehouses), bills to ensure women’s access to reproductive services may fare better in those states than in the past; voters in several other states yesterday advanced measures to greatly restrict access to such services.  For many women, access to necessary services will depend on where they live. 

There are many other issues that are less partisan and may find common-ground in the new Congress, including improvements in the Medicare Quality Payment Program, payment for primary and comprehensive care, reducing barriers to chronic care, addressing the opioids epidemic, and reducing administrative tasks imposed on physicians and patients.

One thing is sure: voters yesterday ranked health care as the most important issue behind their votes, and politicians who ignore them, or let partisan divisions lead to inaction, will do so at their own risk.  

Finding a winning way forward on CMS’s proposals to restructure physician payment

Last month, I wrote about CMS’s “historic” proposals to change how physicians would be paid for their office visits and the documentation that would be required of them. 

I noted then that while ACP expressed strong support for the push to reduce the documentation burden on clinicians, we also expressed concern that flat blended fee could have an adverse impact on internal medicine physicians and subspecialists and their patients.  In an official statement of ACP’s initial reaction to the proposal, issued the day after the proposal was released, ACP President Dr. Ana María López had this to say:

“Reimbursing the most complex E/M services to such patients at the same flat level as healthier patients with less complex problems could undervalue the physician skills and training needed to care for such patients.”

Since then, ACP has heard from many internists who are greatly concerned about the adverse impact of paying a single flat blended fee for levels 2-5 evaluation and management services.  They passionately believe that paying the same amount for the most complex office visits as less complex ones would harm their patients, and must be opposed by ACP.

We agree—CMS’s proposal for flat fee for E/M services is not acceptable.  At the same time, we believe that that the agency’s plan to reduce documentation requirements for E/M services has great value, because E/M documentation is a major contributor to physicians’ frustrations with their EHRs. In a 2015 position paper, Clinical Documentation in the 21s Century, developed by our Medical Informatics Committee, ACP observed that current E/M documentation requirements have fundamentally changed the nature of the clinical note:

 “In place of a thoughtfully written review of systems that listed pertinent positive or negative findings, clinically meaningless terms such as “ten point review of systems was negative” were introduced into the record to satisfy E&M guidelines. Instead of clinical needs determining the level of detail of the physical examination, documentation of the examination was driven by the required number of “bullets” to fulfill the requirements for a specific code.. . what is now illogically considered to be the gold standard of a good note comes not from clinical professors and mentors but from professional coders and corporate compliance training. An imbalance of values has been created, with compliance, coding, and security trumping patient care, clinical well-being, and efficiency. A harshly negative ‘gotcha’ mentality that saps the professionalism out of physicians has also appeared.”

This is still the case, and CMS’s proposals to reduce E/M documentation requirements are a good start in addressing this highly dysfunctional situation.  The problem is that CMS says it can’t reduce E/M documentation unless it goes along with paying a flat fee for E/M services. That’s not a rationale, or trade-off, that ACP can accept. We think that CMS can reduce E/M documentation while preserving the principle that more complex cognitive care should be paid more than less complex care.

ACP, through its regulatory affairs staff with oversight and direction from the physician-members on our Medical Practice and Quality Committee (whose chair and vice chair are both practicing internists in smaller independent practices), is in the process now of drafting official comments on CMS’s proposed rule, due September 10.  While not yet final, I anticipate that our comments will articulate the following key points:

1. ACP strongly believes that cognitive care of more complex patients must be appropriately recognized with higher allowed payment rates than less complex care patients. CMS’s current proposal to pay a single flat fee for E/M levels 2-5, even when combined with proposed primary care and specialist add-on codes and payment for prolonged services, undervalues cognitive care for the more complex patients, potentially creating incentives for clinicians to spend less time with patients, to substitute more complex and time-consuming visits with lower level ones of shorter duration, schedule more shorter and lower-level visits, and potentially, avoid taking care of older, frailer, sicker and more complex patients. It could also create a disincentive for physicians to practice in specialties, like geriatrics and palliative care, that involve care of more complex patients. Accordingly, the proposal to pay a single flat fee for E/M levels 2-5 must not be implemented.

2. ACP appreciates and supports the overall direction of CMS’s proposals to reduce the burden of documentation for E/M services, yet strongly disagrees that such improvements should be contingent on acceptance of CMS’s proposal to pay a single flat fee for E/M levels 2-5. While we understand CMS’s concerns that changes in E/M documentation requirements, without changes in the underlying payment structure for E/M services, could create program integrity challenges, we believe that CMS should consider testing of alternatives that would allow it to move forward on simplifying documentation, ensure program integrity, and preserve the overarching principle that more complex and time-consuming E/M services must be paid appropriately more than lower level and less time-intensive services.

2. ACP urges CMS not to establish a regulatory deadline (e.g. January 1, 2019 or January 1, 2020) for finalizing and implementing its flat E/M fee proposals or possible alternatives that change how E/M services would be paid, and instead, to take the time to “get it right.” Sufficient time must be allowed to engage the physician community to develop and pilot-test alternatives that preserve the principle that more complex and time-consuming E/M services must be paid appropriately more than lower level and less time-intensive services, while allowing CMS to move forward on simplifying E/M documentation while ensuring program integrity. The stakes for patients, clinicians, and the Medicare program are too great for CMS to rush changes

Instead of just telling CMS all of the things that are wrong with their proposal for flat E/M bundled payments (and there are plenty of them, to be sure), we should point them toward a truly winning outcome for physicians, patients, and the program, one that reduces E/M documentation (that has resulted in “compliance, coding, and security trumping patient care, clinical well-being, and efficiency)” while preserving higher payment for more complex cognitive care.

Today’s question: what would you like to hear ACP say in its response to CMS’s proposals?

An Immigrant's Tale

There are many things that make me proud of the American College of Physicians. 

ACP’s courageous leadership in standing up for those seeking to immigrate to the United States is one of them.  Over the past 18 months, ACP has issued a comprehensive statement on immigration policy affirming its opposition “to discrimination based on religion, race, gender or gender identity, or sexual orientation in decisions on who shall be legally admitted to the United States as a gross violation of human rights,” opposed the President’s original Executive Order barring immigrants from six majority Muslim countries because it was discriminatory, and would adversely affect non-U.S. born IMGs seeking to study, train, or provide medical care in the United States; joined in an amicus brief to the U.S. Supreme Court urging that the court overturn a modified version of the ban for the same reasons; issued a statement expressing concern that the Supreme Court upheld the ban; advocated for legislation to provide permanent legal status, and eventually citizenship, for persons enrolled in DACA (Dreamers); successfully advocated to end delays in processing H-1B visa applications from IMGs that were stalled or denied due to increased scrutiny regarding prevailing wage data; objected to the administration’s “zero tolerance” policy of separating immigrant children from parents, or detaining parents and children together in detention facilities, because of the harm to the health of children and their families.

Many other medical organizations have shied away from immigration policy, maybe because it is considered to be too controversial, too complicated, too political, and too divisive, among their own members and the public.  Some may feel that immigration policy is not their area of expertise.

For sure, there are reasons to be cautious about entering the fray: immigration is controversial, complicated, political, and divisive, and physicians are not experts on how to enforce U.S. immigration laws or control access to our borders.

But physicians are experts on how public and social policy affects the health of the public and their patients.  While immigration policy is complicated and controversial, so are many other issues, from gun violence, to high prescription drug prices, to what happens if people are denied access to affordable coverage. Yet, many physician professional societies have tackled those issues, because of their abiding concern for patients. 

While my own family experience has no bearing on ACP policy, it is one of the reasons why I am especially proud of ACP’s willingness to speak out on the impact of immigration policies as a public health and human rights issue.

My father, Jack Doherty, was born poor in Ireland, in a thatched cottage with no plumbing or electricity.  He originally emigrated with my grandmother and grandfather to New York City as an infant. For reasons unknown to me, my dad at age two returned to Ireland with my grandmother, without my grandfather. My grandmother raised my dad as single mother in Ireland on a subsistence farm for eight years, during which they had no contact with my grandfather. When my father was 10, they got a letter from my grandfather asking them to return to NYC to be with him.  They sailed in steerage once again to NYC and were reunited with my grandfather.

My grandfather, Thomas, was a bar-owner and bartender at Doherty’s Bar in Woodside, Queens, NYC.  My father told me he had a very difficult relationship with his father, given that my grandfather had abandoned him and my grandmother for so many years, and my father had grown up without knowing his dad.

Thomas died when my father was only 16. My widowed grandmother took over and ran Doherty’s Bar until my father was 18, and then my father ran it—not as an absent owner, but an owner-bartender who worked six days a week, 10 hour shifts behind the bar, serving shots and beer to blue collar workers.  He married my mother, Marilyn, a few years later, a U.S. born and college-educated woman who  came from a working class Irish-German background.

The bar ended up being successful enough for my mom, three sisters, and I to enjoy a middle-class lifestyle, enabling my siblings and I to go to good schools and colleges and have just about everything we wanted and needed. 

When I was in college, I was the third generation of Doherty men to work behind the bar while  on summer break from college.

Fast forward: my dad decided that being a bartender/bar-owner with only a high school diploma was not giving enough back the country (the U.S, not Ireland) that he so loved. While still tending bar 10 hours a day, six days per week, he went to college at night to get his B.A. in history, and then, a Masters in secondary education. He sold the bar in the late 1970s and became a NYC public school teacher, in a high school that taught mostly underprivileged minority students. He said he wanted to teach disadvantaged minority kids who faced discrimination and hardship because he had been a poor child himself, facing discrimination (the Irish at that time were not welcome by many Americans) and hardship.

Because my grandmother, grandfather, and father came to America to escape dire poverty, my sisters and I had great schooling and a college education. One of my sisters is a U.S. diplomat, one’s an award- winning theater costumer designer; one is a social worker who has spent most of her professional life counseling poor and emotionally troubled teenagers. I, of course, have spent my career advocating for internal medicine physicians.  The advantages we have had have been passed on to our children.

My dad passed away 11 years ago.  His immigrant story, like millions of others, is what truly makes America great: unskilled, poor people coming to America to improve their lives, and by doing so, improving America. 

So, when ACP speaks out for the unskilled, poor people coming to America today to improve their lives, it resonates with me. And makes me so proud. 

Today’s questions:  What is your view on ACP taking on immigration policy?  And do you have a family immigration story you want to share?

FOUR things you should know about Medicare’s “historic” changes to physician payments

The word “historic” is often used by PR professionals to hype something that is, well, pretty run-of-the-mill.  They figure that no one is going to read a news release that announces “[Name of organization] proposes small change that really won’t make much of a difference.”  The problem is that when something is done that really measures up to being historic, the recipient is less likely to believe it, kind of like the constant Breaking News chyrons loved by cable news shows. 

Yesterday, CMS—the agency that runs Medicare—issued a press release announcing “Historic Changes to Modernize Medicare and Restore the Doctor-Patient Relationship.”  You know what? This one may actually live up to the billing!

CMS is proposing to radically overhaul how it pays physicians for office visits and other evaluation and management (E/M) services; to lift restrictions on payment for telehealth consults and other physician services that are not part of the office visit itself; and to ease the myriad of crushing administrative tasks imposed on physicians to document their services or to get credit for participating in Medicare’s Quality Payment Program.

Both of CMS’s proposed rules are thousands of pages long, so few readers of this blog will be up to reading them. (Never mind trying to decipher the technical and legalistic language used for federal rulemaking!)  Fortunately, ACP’s crackerjack regulatory affairs staff was at it late last night and early this morning (when do they sleep???), to go through it and find out what is to like, and not like, about it.

They found that there is much to like.  Based on their review, ACP released a statement just a short while ago that expressed optimism that many of the proposed changes will “streamline burdensome administrative and documentation requirements –a proposal that is in line with ACP’s Patients Before Paperwork initiative” as Ana María López, MD, MPH, FACP, president, ACP, put it.  ACP also cautioned, though, that one of the biggest changes proposed by CMS—paying a flat fee for most office visits, regardless of their complexity—needed greater examination because of its potential to undervalue the skill and training required of physicians to take care of patients with more complex medical conditions.

There are 4 BIG changes proposed by CMS that are noteworthy:

1.  CMS proposes to make it less burdensome for physicians to participate in its Quality Payment Program, including streamlining the Promoting Interoperability MIPS category by removing the separate components within the Promoting Interoperability (formally Advancing Care Information) Category score to create a streamlined scoring methodology, increasing the ways in which physicians and other clinicians can qualify for the low-volume threshold  and removing a number of quality measures deemed by the agency to be of low-value, consistent with recommendations by ACP and its Performance Measurement Committee.

2.  CMS proposes to pay for more physician services that are not part of a face-to-face office visit. CMS proposes to add new reimbursable codes for “virtual check-ins,” remote consults of patient videos and photos, and interprofessional online consultations.

3.  CMS proposes to take major steps to reduce the documentation requirements associated with evaluation and management (E/M) services, by allowing medical decision making to be the basis for documentation, requiring physicians to only document changed information for established patients and to sign-off on basic information documented by practice staff. ACP strongly supports these changes, as they will reduce the documentation burden on clinicians, limit redundant information in the medical record, and cut down on duplicative time spent on re-documenting existing information.  CMS also proposes to create add-on codes for primary care visit complexity.

4.  CMS proposes to create a flat, single blended payment for most office visits, regardless of their complexity.  ACP expressed concern that this proposed payment structure potentially could have an adverse impact on internal medicine physicians and subspecialists and their patients, since internists typically take care of elderly patients with multiple chronic conditions.  “While we acknowledge the potential benefit of simplifying billing and associated documentation of E/M services by bundling levels 2-5 together, ACP will be assessing whether this change will have the unintended impact of undervaluing the work associated with caring for more complex and frail patients” Dr. López observed. “Reimbursing the most complex E/M services to such patients at the same flat level as healthier patients with less complex problems could undervalue the physician skills and training needed to care for such patients.”

There is much more to the proposed rules, including several areas where it fell short in ACP’s opinion.

Still, the overall direction of easing the burdens of participating in Medicare’s QPP, simplifying requirements to document office visits, paying for telehealth consultations and other work that falls outside of an office visit, and yes, the proposal to pay a flat fee for office visits of varying levels of complexity (whether this turns out to be a good idea or not after further examination of its impact), might just live up to being “historic.” 

Today’s question: what do you think of CMS’s “historic” proposals to change Medicare payments to doctors and its Quality Payment Program?

Physician activism as an antidote to burnout

The growing number of physicians evidencing symptoms of burnout has many causes.  Yet one element stands out, according to research: a perceived loss of control over their time, working conditions, and other stress contributors.   ACP has launched a Physician Well-being and Professional Satisfaction Initiative that includes resources promoting individual well-being, advocating for system changes, improving the practice environment, and fostering local communities of well-being.  ACP’s Patients Before Paperwork is about challenging administrative tasks that contribute to burnout.

Yet over the past three days, I’ve observed another promising antidote to burnout:  individual and collective physician activism to change policies that affect their daily work and professional development.  Nearly 400 ACP members from 48 states and the District of Columbia came to Washington, DC to participate in our  annual Leadership Day on Capitol Hill.  Yesterday, they learned about how to be effective advocates with their elected lawmakers, the political and legislative environment in Congress, and the issues that ACP was asking them to bring to Congress. 

This morning, they heard from Rep. Peter Roskam (R-IL), chair of the Ways and Means health subcommittee, on the subcommittee’s Medicare Red Tape initiative, which gives clinicians the opportunity to inform lawmakers about administrative tasks that could be modified to make them less burdensome, if not eliminated altogether. Then, former CMS administrator CMS Andy Slavitt, recipient of ACP’s 2018 Joseph F. Boyle award for Distinguished Public Service, suggested to the attendees that health care proposals should be evaluated based on a simple test: does it make it easier or harder for patients to get the care they need? 

The attendees then headed to Capitol Hill, meeting with members of Congress and staff from their own states, presenting ACP’s ideas, as supported by their own personal experiences with patients, for improving patients’ care and physicians’ daily lives and professional development.

What does all of this have to do with physician burnout?  The doctors and medical students I observed this week were anything but a dispirited or despairing group, but happy and enthusiastic activists for their patients, and their profession.

When you think about it, it makes perfect sense that physician activism is a powerful antidote to burnout.  If burnout is about losing control, activism is about taking it back.   Physician-activists don’t accept a status quo that devalues the doctor-patient relationship, they advocate for policies to make things better.  As Margaret Meade once said, “Never doubt that a small group of thoughtful, committed, citizens can change the world. Indeed, it is the only thing that ever has.”

There is nothing more empowering than that.

Are doctors ready to embrace single payer health care?

Single payer health care is enjoying a boomlet in public opinion. 

A Pew Research Center poll released in June 2017 found that, “Overall, 33 percent of the public now favors such a ‘single payer’ approach to health insurance, up 5 percentage points since January and 12 points since 2014.”  58 percent of those surveyed by Pew said that the government has a responsibility to ensure health for all, with a third saying it should be through a single national government program and 25 percent through a mix of government and private programs.  Another 33 percent said the government is not responsible to ensure health care for all but agreed that Medicare and Medicaid should be continued, while 5 percent said the government should not be involved at all. The poll also showed that a majority of Democrats now favor single payer; support was also stronger among younger persons than older ones.  However, most Republicans and older voters oppose single payer.

Source: Pew Research Center

The Kaiser Family Foundation’s June 2017 tracking poll found even higher levels of support for single payer, with 53 percent in favor and 43 percent opposed.  However, it also described support for single payer as being “malleable” and subject to change when presented with arguments for or against: “While a slim majority favors the idea of a national health plan at the outset, a prolonged national debate over making such a dramatic change to the U.S. health care system would likely result in the public being exposed to multiple messages for and against such a plan. The poll finds the public’s attitudes on single-payer are quite malleable, and some people could be convinced to change their position after hearing typical pro and con arguments that might come up in a national debate.”

A Harvard-Harris poll conducted in September 2017 found even higher levels of support for single payer, with a narrow majority (52 percent) supporting it while 48 percent opposed. 

Doctors also appear to be warming to single payer, according to some recent polls.  And, as I have traveled around the country in recent months to visit ACP chapter meetings, I’ve found more and more ACP members are advocating that the College come out strongly in favor of single payer health care, and not just in so-called liberal leaning “blue” states.  I’ve explained that a 2008 ACP paper, which I co-authored on behalf of our Health and Public Policy Committee, examined what the United States could learn from other countries’ health systems.  We recommended “that the federal and state governments consider adopting one or the other of the following pathways to achieving universal coverage:

1. Single-payer financing models, in which one government entity is the sole third-party payer of health care costs, can achieve universal access to health care without barriers based on ability to pay. Single-payer systems generally have the advantage of being more equitable, with lower administrative costs than systems using private health insurance, lower per capita health care expenditures, high levels of consumer and patient satisfaction, and high performance on measures of quality and access. They may require a higher tax burden to support and maintain such systems, particularly as demographic changes reduce the number of younger workers paying into the system. Such systems typically rely on global budgets and price negotiation to help restrain health care expenditures, which may result in shortages of services and delays in obtaining elective procedures and limit individuals' freedom to make their own health care choices.
2. Pluralistic systems, which involve government entities as well as multiple for-profit or not-for-profit private organizations, can assure universal access, while allowing individuals the freedom to purchase private supplemental coverage, but are more likely to result in inequities in coverage and higher administrative costs (Australia and New Zealand). Pluralistic financing models must provide 1) a legal guarantee that all individuals have access to coverage and 2) sufficient government subsidies and funded coverage for those who cannot afford to purchase coverage through the private sector.”

(Note that this paper was written a year before the Affordable Care Act (ACA) became law; the ACA is an example of the second option, although it has fallen short of assuring universal access).

Recognizing the growing interest in single payer, and in other models that may still involve multiple payers but with the government having a much large role in financing and ensuring coverage (most European countries are not truly single payer, because they still allow some role for private insurance), ACP’s Health and Public Policy Committee will over the next several months begin examining different alternatives to advance universal coverage.   As it does, I think there are several important questions that will need to be asked, particularly of single payer:

1. Will all Americans be required to get their coverage through a single, government-financed system (compulsory coverage), meaning that they would have to give up their employer-based or individual coverage?  (If not, it really isn’t single payer; if so, will Americans react favorably to being compelled to get their coverage from the new program?)
2. Related, will Americans conclude that the coverage under the new program is better or worse than what they have now?  Will deductibles and co-payments be higher or lower?  Many single payer advocates assume that deductibles will be lower under single payer than most Americans typically now pay, but that is in no way a given; one could imagine a single payer plan based on the ACA’s silver plans, for instance.  Will the covered benefits be more or less generous?  Will premiums—or if funded solely through taxes, the taxes they pay—cost them more or less compared to what they and their employers now contribute?  Will taxes be progressive, meaning the wealthier pay more, or regressive, as is the case with Social Security taxes?  Will they have limited networks of physicians and hospitals, like Medicare Advantage plans, or complete choice of physician and hospital, like traditional Medicare?  Will they and their physicians be able to have access to any FDA-approved prescription drugs, or will there be a limited formulary to choose from?
3. Will the government contract with insurance companies to run the new system, like is the case today with Medicaid managed care, Medicare Advantage, and even Medicare Part B (administered by private insurance carriers) and Part D (pharmacy benefit managers)?  It would be so typically American to create a single payer system, and then pay insurers to administer it.
4. How will costs be controlled?  With global budgets, price controls, limits on capacity, and/or limiting access to care based on determinations of quality-adjusted life years like in other countries? How will physicians, hospitals, drug companies, and medical device manufacturers be paid?

This may seem like I am arguing against single payer; I’m not.  The same questions might be asked of other approaches.  And models that continue to rely on multiple payers, as is the case with the ACA, may never be as effective and efficient as a single payer system in ensuring that everyone has affordable coverage. Single payer almost certainly would have lower administrative costs and be more egalitarian.

Rather, what I am suggesting is that as ACP, and the country, considers different approaches to achieve universal coverage and access (not the same things), the questions that will need to be considered are far more complex than the snapshot (do you favor or oppose Medicare for All) questions asked in polls.  How those questions are answered will likely determine if the public, and physicians, are truly ready to embrace single payer health care.

Today’s question: What is your view of single payer (Medicare for All) health care?

What did ACP advocacy achieve in a year of unparalleled challenge?

What did ACP advocacy achieve in a year of unparalleled challenge?

2017 was the most challenging year that I have experienced in my 38 years of advocating for internists.

To put things in perspective, I joined the governmental affairs staff of the American Society of Internal Medicine in January 1979, during the presidency of Jimmy Carter.  I had the privilege of helping ASIM advocate for internists for 19 years, until ASIM merged with ACP on July 1, 1998, and then continuing after the merger as Senior Vice President for ACP’s Division of Governmental Affairs and Public Policy.  From Jimmy Carter to Ronald Reagan, to George H.W. Bush, to Bill Clinton, to George W. Bush, to Barack Obama, I have seen both ASIM and ACP skillfully navigate the challenges associated whenever there is a new occupant in the White House, and also, changes in which party controls the House and Senate. 

If you choose to participate in advocacy in Washington, or in state capitals for that matter, change and disruption are par for the course. For instance, it is hard to overstate how big a change Ronald Reagan’s policy agenda was from the policies pursued by Jimmy Carter, or Barack Obama’s compared to George W. Bush’s.

Yet there has never been a more challenging, and disruptive shift in policies and priorities than since President Trump was elected and became president, just shy of one year ago. After all, he ran on a platform of ending as much of President Obama’s legacy as possible, including a promise to repeal Obama’s signature achievement, the Affordable Care Act (ACA), “on day one” of his presidency.  With the Republicans controlling both chambers of Congress, there was reason to believe he would succeed, if not on day one, during the first year of his administration.

As a result, ACP spent much of last year playing defense on the ACA, which we support, and also on several other priorities, where the current administration's and congressional leadership's priorities were at odds with long-standing ACP policy.  This was not our choice: as a strictly non-partisan organization, our hope is always to find common ground with a new president and Congress wherever possible, to compromise when needed, and to resist only when necessary.  And in some cases, we have been able to find common ground with President Trump and Congress.  Yet we have also had to defend repeated attacks on programs, policies and priorities that we believe are essential to the health and well-being of patients.

So how did we do, in such a year of unparalleled challenges to our advocacy agenda?  Pretty darn well, I’d say:

• On Coverage and Access:  While many Americans believe otherwise, the ACA was not repealed.  Except for repeal of the ACA’s requirement that individuals purchase insurance, all the rest of the ACA remains the law of the land, including coverage of essential benefits, preexisting condition protections, no lifetime limits on coverage, and premium and cost-sharing subsidies.  Medicaid was not capped and cut.  ACP specifically helped derail the Graham-Cassidy bill, which would have radically devolved responsibility for funding and regulating coverage from the federal government to the states, causing tens of millions to lose coverage and benefits.  Repeal of the individual mandate, which was included in the tax bill, is of concern to the ACP, because it likely will further destabilize insurance markets.  Nonetheless, the fact that the rest of the ACA has survived, despite President Trump’s repeated calls for repeal followed by repeated (failed) votes in Congress to repeal it, is a huge win for ACP advocacy.
• On women’s access to health care: Planned Parenthood was not defunded.  And the administration's interim final rule to allow employers to opt out of contraceptive coverage, which ACP opposes, has been blocked by two recent court decisions, at least for now.
• On health care expense and tuition interest deductions:  ACP achieved several big wins in the tax legislation that passed Congress in late December:  the deductibility of student loans and medical expenses was preserved, even though an earlier version of the bill passed by the House of Representatives would have repealed both.    
• On insurer mergers: The courts blocked two mega insurer mergers that would have reduced competition and harmed physicians and patients.
• On non-discrimination against transgender persons: The courts stepped in to block the administration's ban on transgender persons serving in the military, consistent with ACP’s opposition to the ban. 
• On immigration and health: Court decisions have also resulted in the administration substantially modifying its original executive order on immigration in a way that, while still concerning, is less damaging to the ability of physicians trained in the affected countries to enter and remain in the United States under legal visas. 
• On reducing paperwork: We were able to advance our policy agenda as it relates to Patients Before Paperwork to the point where the administration has launched a similar initiative, called Patients Over Paperwork. 
• On improving quality payments: We achieved substantial wins in improving the Medicare Quality Payment Program and payment for internists' services, particularly by easing the burden on smaller practices. Dr. Louis Friedman, an ACP member, was asked to testify on his experiences with the CPC+ APM model before the Energy and Commerce health subcommittee, invited by both the majority (R) and minority (D) leadership of the committee—a testament to the high regard that both parties hold of ACP when it comes to payment and delivery system reforms. 
• On addressing the opioids crisis: The President’s Commission on Opioids issued a report that is largely consistent with ACP’s recommendations, including a recommendation to establish drug courts in all jurisdictions.
• On prescription drug pricing: The National Academy of Medicine issued a report on prescription drug pricing that also closely reflected ACP’s recommendations; several ACP-supported bills were introduced in Congress to address the high cost of prescription drugs.
• On climate change: While the administration's approach to climate change remains very concerning, states, localities, and businesses have stepped up to adopt measures to mitigate climate change. 
• On firearms: ACP and its Florida chapter had a big win when a federal appeals court overturned a Florida law that prohibited physicians from discussing gun safety with patients. Many states and localities have stepped in to adopt policies consistent with ACP's recommendations, by expanding background checks and other common-sense regulations while beating back the gun lobbies' efforts to make guns even more available.  

Of course, ACP didn’t achieve all of these wins completely on our own. Advocacy is never won through the efforts of only one engaged actor; rather, it is the result of many with shared interests joining together to combine their efforts to achieve a common end.  2017 was the year that 6 physician professional organizations—ACP, the American Academy of Pediatrics, American Academy of Family Physicians, American Osteopathic Association, American Congress of Obstetricians and Gynecologists, and the American Psychiatric Association came together to form the “Group of 6” coalition, representing a combined membership of over half a million doctors and medical student members.  The Group of 6 has now become one of the most influential (and largest!) health care coalitions in Washington, with 6 leadership fly-ins to Capitol Hill in 2017 and another scheduled for next week.

Particularly in challenging times, determined advocacy is what is most needed to make a difference for the better.  In 2017, ACP passed the test, with flying colors.

Today’s question: what is your take on ACP’s advocacy in 2017?