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Sequestration’s cutbacks could cause patients serious harm

From the May ACP Internist, copyright © 2013 by the American College of Physicians

By Robert B. Doherty

Congress and the White House have known since the summer of 2011 that across-the-board cuts in the federal budget, called sequestration, would happen on the first of this year if they didn’t come up with an alternative plan. Yet they did nothing to reach a bipartisan accord besides broker a short-term deal on Jan. 1 to postpone the cuts until the first of March. Then—surprise, surprise!—they allowed the new deadline to come and go, and sequestration went into effect as scheduled. The biggest impact is not expected to be felt until late spring and summer, when up to 1 million federal employees will start being furloughed, one day per week of mandatory unpaid time off.

Keep in mind that Congress and the White House never intended for sequestration to happen. It was supposed to be a back-up mechanism to force an agreement on a better way of achieving equivalent savings. But congressional Democrats, Republicans and President Obama were unable to agree on a package that would include enough revenue (as defined and demanded by the president and congressional Democrats), enough reforms in entitlement programs including Medicare and Medicaid (as defined and demanded by congressional Republicans), and more judicious cuts in discretionary programs while protecting funding for essential programs (as Republicans and Democrats alike say they want, even as they disagree on how much of the savings should come from defense versus domestic programs).

The American College of Physicians has been on record since January 2011 as believing that “sequestration must not stand.” The College repeated its concerns in numerous letters to Congress and again in this year’s annual report on the state of American health care, released on Feb. 20. ACP observed that “These ill-considered and arbitrary cuts will affect almost every federal program that protects the health and safety of the American people,” from the NIH to the FDA to CDC to Medicare.

Yet so far, the public seems unconcerned about the cuts. Rather, most say they support cutting the budget along the lines mandated by sequestration. A recent ABC News/Washington Post poll found that “by nearly 2-1, 61-33 percent, [the public] supports cutting the overall budget along the lines of the sequester ... But by nearly an identical margin, Americans ... oppose an eight percent across-the-board cut in military spending.”

The relative unconcern about nondefense cuts shown in the poll may be because it was taken right after sequestration technically was ordered, weeks or even months before voters would see most of its effects. And the public’s expressed agreement with achieving savings comparable to those mandated by sequestration does not mean that the public will favor specific cuts once they see how those cuts will affect them personally.

Darren Samuelsohn at Politico, which covers national politics, reported online that members of Congress, both Republicans and Democrats, are concerned as the full impact of the cuts are felt in their own districts. “Rep. Bill Enyart might be a Democrat and Rep. Rodney Davis a Republican, but the two rookie lawmakers in Southern Illinois share one fear. Sequestration could cost them their seats. Enyart and Davis are three months into their new jobs—representing next-door districts—and constituents already are blaming them for not doing enough to stop the automatic spending cuts,” Mr. Samuelsohn wrote.

Yet the longer much of the public seems unconcerned about sequestration, the more damage it will cause to vital programs. Physicians, especially, should be speaking out, yet some ACP members have told me that they felt sequestration is “necessary” to reduce federal spending.

I explained to them that the issue isn’t whether the budget deficit needs to be reduced, but how, and sequestration is the wrong way to go about it. Beyond being a colossal failure of the process of governing, substituting budgeting-by-formula for building consensus on spending priorities and taxes, sequestration will do real damage, to real programs serving real people, with health care getting hurt more than any sector other than defense.

  • The NIH will be cut by over $2.5 billion this year alone, more than half of the entire budget for the National Cancer Institute. Francis Collins, MD, PhD, the NIH’s director, said in a report from Research America, “Sequestration: Health Research at the Breaking Point” (online at ww.researchamerica.org/uploads/RASequestrationReport.pdf), that this would “result in roughly 2,300 grants that we would not be able to award in FY13 that we otherwise would have expected to.”
  • The CDC will be cut by $45 million, more than its entire spending in 2011 for its grant immunization program. “An 8%-10% reduction, on top of 50,000 front-line public health professionals already lost at the state and local levels, will risk costly and deadly spread of disease and failures to prevent tragic and expensive health problems,” said CDC director Thomas Frieden, MD, MPH, also in the Research America report.
  • The FDA will be cut by $191 million, more than its entire budget for premarket review of new drugs.
  • Cuts in federal workforce programs will lead to fewer scholarships for minority medical students and reduced funding for training grants to thousands of primary care physician and physician assistant trainees.
  • Medicare will be cut by $11 billion—including a 2% cut in payments to physicians, hospitals, and graduate medical education programs, effective April 1.

One would have to wear rose-colored glasses to conclude that these (and other sequestration cuts) won’t hurt the health and safety of the American people.

It is time for physicians to insist that members of Congress reach a bipartisan agreement with the president to replace sequestration with a more judicious and responsible approach, one that reduces spending on less effective and lower-priority programs, preserves or increases funding for more important and more effective programs, and trims health care spending by focusing on unnecessary care, not through arbitrary payment cuts. It should be an approach that ensures sufficient revenue to support vital programs, before too many people are hurt by diseases that won’t be cured or prevented, by physicians who won’t be trained, by drugs that won’t be approved, and by fewer physicians and hospitals being available for persons enrolled in Medicare.

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