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Can we achieve reform in a presidential election year?

From the March ACP Observer, copyright © 2004 by the American College of Physicians.

By Robert B. Doherty

If past experience is any indication, major health legislation is unlikely to pass in a presidential election year. That's because both parties are more interested in seeking a political advantage in the upcoming elections than in getting much of substance done.

Democrats, for instance, will try to persuade voters that Republican control of the White House and Congress has led to a growing number of uninsured Americans. President Bush and the Republican congressional leadership will try to use the medical liability crisis to their advantage by scheduling votes on measures to cap noneconomic damages, even though they know there are not enough votes in the Senate to get such measures passed.

Both sides will be busy trying to score political points, with no real incentive to seek the bipartisan compromises needed to get legislation passed.

How can ACP move its agenda forward in such a highly politicized, partisan environment? It might be tempting to simply accept the fact that we won't be able to get much done and set our sights lower accordingly. But instead of pulling back and pursuing only modest goals, the College has decided to push ahead with a comprehensive advocacy and policy framework to reform the U.S. health care system.

The decline in the nation's health care

The College summarizes the problems facing the health care system in a new report, "The State of the Nation's Health Care: A Report from America's Internists." The report, which was issued a few days before President Bush's State of the Union Address, examines several key measures and concludes that the state of the nation's health care is declining.

Here are some of the key measures the report examined:

  • The rising number of Americans without health insurance. According to the Census Bureau, an estimated 15.2% of the population, or 43.6 million people, went without health insurance coverage for the entire year in 2002. (That's the most recent year for which data are available). That number was up from 14.6% in 2001, for an increase of 2.4 million people.

  • The loss of safety net programs for low-income Americans. Thirty four states representing every region of the country have made cuts that have dropped up to 1.6 million low-income families and individuals from programs like Medicaid and the State Children's Health Insurance Program.

  • Rising out- of- pocket expenses for individuals enrolled in employer-based plans. Analysts estimate that employers increased employees' portion of health care premiums by up to 3% in both 2002 and 2003.

  • Stalled federal legislation to address medical liability premium problems. While some state legislatures have acted to address this problem, liability insurance problems continue to escalate, putting more states in crisis—and hurting patient access to care.

  • A marked decrease in the number of physicians entering internal medicine and other primary care specialties. This decline has been accelerating over the past four years, even though demographic trends suggest that more general internists and other primary care physicians will be needed to manage the care of older patients with chronic disease.

    On a positive note, the College's report noted that the Medicare Prescription Drug Improvement and Modernization Act of 2003 was passed last December, temporarily stabilizing Medicare payments to physicians and slowing growing access problems for beneficiaries.

    The report also pointed out that the Bush administration and Congress have taken important first steps to address the paperwork burdens that unnecessary Medicare regulations have placed on physicians.

    Those efforts, however, have not been sufficient to slow the avalanche of paper being imposed on internal medicine practices. According to a recent survey, three-quarters of physicians expressed dissatisfaction with Medicare paperwork, and half said they have hired additional administrative and billing staff to cope with the growing burden.

New policy framework

Despite limited progress, it is clear that the current federal strategy of dealing with the challenges of decreased coverage, access and quality in a piecemeal fashion is not working. We need a new and comprehensive federal initiative.

The College has proposed a coordinated policy framework that will improve the health care system through a series of actions: expanding health insurance coverage; reducing the amount of time physicians spend on paperwork and administration; improving quality, productivity and physician and patient satisfaction through investment in interoperable electronic health technology; and creating incentives for physicians to enter and remain in the specialty of internal medicine.

Here is an overview of the four steps ACP believes are necessary to reform U.S. health care:

  1. First, ACP calls on President Bush and Congress to work toward agreeing on legislation to ensure that all Americans with incomes up to 150% of the federal poverty level would have access to affordable coverage no later than Jan. 1, 2007.

    Congress should provide states with new options and guaranteed federal funding to make existing safety net programs more effective. Legislators also must give tax relief subsidies and create purchasing arrangements to help eligible individuals and families. (For more on the College's proposals, see "ACP's positions on expanding access to care.")

  2. Second, the College urges Congress, the administration and health insurers to institute reforms to drastically reduce the time physicians need to spend completing paperwork for third party payers. Our goal is to reduce that average amount of time by half by Jan. 1, 2007.

    ACP proposes achieving those reductions by eliminating duplicate forms and unnecessary regulations, easing documentation and billing requirements, and developing "paperless" alternatives to paper forms.

  3. Third, the College is asking Congress and the administration to provide the resources and policies needed to encourage physicians to voluntarily move from paper-based systems to computer-based information technologies.

    Electronic health records and other information technology offer the potential for making medical practices more efficient, reducing medical errors, and allowing for faster communication of clinical care and test results. But the federal government must focus its efforts on addressing the practical barriers physicians face in acquiring information technology.

    Those barriers include: the high costs of purchasing electronic health record systems and training physicians and staff to use them; concerns about interoperability with other health information systems; the lack of accepted industry standards; the inability of physicians to share in system-wide savings from information technology; and the financial risk of investing in technologies that may soon be obsolete.

  4. Fourth, the College calls on the administration and Congress to develop and implement policies to address the need for an adequate supply of physicians in primary care specialties. Policy-makers need to make sure that the country has enough internists to care for an aging population and the related chronic disease.

    Workforce policies also should include measures to reduce student debt, ensure adequate funding for Title VII health professions programs, and improve the effectiveness of the National Health Services Corps and other programs that fund primary care training in exchange for service in areas with physician shortages.

    Federal policies should also increase Medicare reimbursement to keep pace with the costs of running an internal medicine practice. Legislators also need to identify innovative ways to reimburse internists for the value of coordinating patient care, and allow internists to share in system savings for managing care effectively.

Challenging the status quo

A presidential election year may not be the best time to try to pass bills into law. But it is the best time to take advantage of the spotlight that will be placed on the state of the nation's health care to illuminate problems and encourage discussion of proposed solutions.

The College's stature and influence in Washington can only grow from our willingness to participate in a renewed national discussion on how to reform the health care system. Even if we don't achieve immediate success as measured by the number of bills we get passed in Congress, our advocacy efforts can help bring the country closer to a national consensus on expanding health insurance coverage, reducing the time spent on paperwork and administration, achieving the benefits of electronic health information technology and revitalizing internal medicine.

Robert B. Doherty is ACP's Senior Vice President for Governmental Affairs and Public Policy.

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