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The president—and the College—address U.S. health care

From the March ACP Observer, copyright © 2005 by the American College of Physicians.

By Robert B. Doherty

Each year, the president engages in a two-step process to communicate his priorities to the Congress and the nation.


College President Charles K. Francis, FACP, addresses reporters at the 'State of the Nation's Health Care' briefing.



The first is the State of the Union address, which typically outlines in broad strokes his goals for the coming year. One week later, the president submits his budget to Congress. Compared to the soaring rhetoric of the State of the Union speech, the budget is anything but uplifting. But in many respects, it is a much more telling indicator of the administration's priorities because it outlines exactly which of his broad goals might actually be backed up with funds.

President Bush's health priorities

President Bush's State of the Union address called for several laudable goals. They include a comprehensive health care agenda with tax credits to help low-income workers afford coverage; more community health centers; enhanced information technology to prevent medical errors and reduce costs; association health plans for small businesses and their employees; and medical liability reform "that will reduce health care costs and make sure patients have the doctors and care they need."

His budget reflects these priorities. If approved, the budget would provide $125 million to support the development of a national interoperable information system within 10 years—a relatively small portion of what will be needed, but a start nonetheless.

The budget included a request to fund 1,200 new or expanded community health center sites to serve an additional 6.1 million people. It proposed a $3,000 tax credit to help uninsured persons buy coverage, and it called on Congress to pass legislation to let small business employers join together to buy joint coverage—known as association health plans—that would be exempt from state-mandated benefits.

At the same time, however, other proposals within the president's budget would substantially reduce or eliminate funding for important health care programs. For instance, his budget would eliminate funding for primary care health professions training grants.

The budget provides no increase in funds for the Agency for Healthcare Research and Quality (AHRQ), which supports research to improve outcomes and quality improvement and measurement. (After inflation is taken into account, AHRQ's funding would actually decline.) And while overall federal contributions to Medicaid would continue to rise, the budget calls for substantial Medicaid savings by closing loopholes and achieving efficiencies in how states run their programs. Critics of the president's Medicaid savings plan believe the net effect would be to force states to drop coverage or limit benefits for many of those who are currently eligible.

Of particular concern, the budget does not include money to halt scheduled cuts in Medicare payments to physicians. Under current law, those payments will decline by an estimated 30% between 2006 and 2013. Legislation to avert such cuts would require Congress to spend as much as $100 billion more over the next 10 years.

ACP's 'State of the Nation' address

On the same day as the president delivered his State of the Union speech, ACP held its own "State of the Nation's Health Care" press briefing. The College issued a report on the strengths and weaknesses of the nation's health care system, and proposed solutions for many of the most pressing problems.

The report expressed concern about the large number of Americans without health insurance coverage; rising health care costs, as reflected in higher premiums and increased Medicare and Medicaid spending; the unacceptably high rate of medical errors; and what the Institute of Medicine called "the quality chasm"—that gap between scientifically determined appropriate care and the care most Americans routinely receive.

The College argued that the most effective strategies to address the problems of cost, quality and access are ones that support the relationship between patients and their own physicians. It is within this relationship, the College claimed, that the quality, appropriateness and effectiveness of medical services are determined.

Too often in the past, the federal government and private payers have instituted cost control policies that created a barrier between patients and physicians, rather than supporting them. The College proposed the following new policy directions to support and strengthen the patient-physician relationship:

  • Stabilize Medicare payments. Congress should enact legislation to halt anticipated cuts to physician payments. ACP noted that physicians will be unable to invest in health information technology and other practice improvements if they are having trouble even making payroll because of reduced reimbursements.

  • Provide information technology incentives. Congress and the administration should provide physicians with funding and reimbursement incentives so they can buy health information technology, giving them immediate access to up-to-date, evidence-based information on prevention, diagnosis, treatment and disease management.

  • Expand demonstration projects. Congress and the administration should expand existing demonstration projects that give physicians a choice in how they get paid, based in part on how well they do in reaching evidence-based quality goals.

  • Institute a chronic care management fee. Congress should authorize a new pilot program to give internists the choice of receiving a chronic care management fee, which would encompass their use of health information technology and other improvements to support physicians in coordinating the care of chronically ill patients.

  • Enact tort reform. Congress should reform the medical liability tort system to help restore the trust between patient and doctor.

  • Increase health care coverage. Congress should expand health insurance coverage so patients who lack insurance will no longer be prevented from establishing an ongoing relationship with a physician.

A starting point

The president's State of the Union remarks and his budget mark the beginning of what will be a long and controversial political process. Congress must now decide which of the president's priorities get funded and by how much.

For our part, the College will call on Congress to support the president's agenda on reforming the medical liability system and encouraging the broad use of health information technology to support quality improvement. However, we will also urge Congress to modify the president's priorities in other areas by working to halt scheduled Medicare payment cuts, avert Medicaid cuts that could lead to more uninsured Americans and maintain adequate funding for other essential health programs.

Next year, when the College again issues its "State of the Nation's Health Care" report, we hope to show progress in achieving reforms that strengthen the patient-physician relationship. We will look specifically for measurable results in creating reimbursement incentives for health information technology and quality improvement, stabilizing Medicare payments, preserving safety net programs, reforming the medical liability system, and reducing the nation's number of uninsured.

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

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