Thursday, January 4, 2018

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?