AMA Journal of Ethics^®

While I was meeting with constituent groups on Capitol Hill last year, one owner of more than thirty fast food restaurants said to me, “Most of my employees are single mothers in college—what do they need health insurance for?” Not until this surprising conversation did I fully appreciate the responsibility I had as a congressional fellow in the United States Senate. We doctors should not only advocate for the needs of our patients and our profession but also protect what we have achieved so far in health care.

During my timeas a resident and fellow in New York, I was a member of the local board of child psychiatrists and attended events in the state and in Washington D.C. to promote a broader understanding of mental illness and the needs of our patients. In doing so, I began to take an interest in federal governance. This past year, I was the Irving Berlin, MD Congressional Fellow through the American Academy of Child and Adolescent Psychiatry (AACAP), working in Senator Debbie Stabenow’s (D-MI) office. Senator Stabenow, who is a social worker as well as a member of the Senate finance subcommittee on health care, has been a great advocate for health care reform.

If you’re a physician, you do not see how connected medicine is to politics and business until the day that your grant is not renewed and your research and position are in jeopardy, your patient is refused an intervention, or your facility shuts down. For me it was learning about my residency program’s termination as a result of its hospital’s bankruptcy and closing. Watching Saint Vincent’s Hospital shut its doors, I saw how medicine is affected by business as well as state and local politics. Why didn’t the hospital’s board foresee and prevent this? Why couldn’t the state intervene? I was not able to find any convincing answers to these questions while patients, trainees, and attendings scattered to other hospitals and clinics.

My first day on Capitol Hill reminded me of my first day as a medical student on the wards—I had no idea what to expect, but it turned out to be a dynamic and rewarding experience. During my fellowship year, I was involved with such matters as amendments to health IT programs; facilitating more coordination between departments with regard to children; correcting the sustainable growth rate (SGR) with the Protecting Seniors’ Access to Doctors Act (S. 3965); promoting federally qualified mental health centers; heart disease education and research, and resolutions on ovarian cancer, health IT, and Parkinson disease. A typical work week brought meetings with groups who came to the office to advocate for their organizations’ priorities, health care committee meetings and briefings, the drafting of many memos on the topic of the day, and the everyday interactions I had with Senator Stabenow’s health care staffers. Almost none of them have worked in a health care setting, but they wield significant influence on health care reform. These relationships showed me how important it is for physicians to offer our knowledge and experience to this energetic and dedicated group. By explaining the clinical implications of proposed policy changes, I was able to contribute as staffers formulated their support of portions of legislation.

In turn, the health care staffers taught me to understand the broader view. Too often we become fixated on one specific concern and lose sight of the big picture. This was evident to me throughout the year—people advocated repealing the entire health care reform bill because the legislation was not everything they had envisioned. It’s this lack of support of big-picture ideas that could drag health reform backward. With the signing of the Patient Protection and Affordable Care Act (ACA) in March of 2010, we took a step in the right direction, toward addressing the soaring costs of health care and including many Americans who might otherwise have faced obstacles to obtaining or maintaining coverage. The senator’s legislative director helped me understand the nature of health reform by saying, “In 2010, we just gave birth…that’s it. Now we will need to nurture and teach our baby through the terrible twos and the rest of childhood, and then we can look back and feel proud of our accomplishment.”

Lessons from Capitol Hill

The fate of the health care reform bill is still uncertain. The Supreme Court’s ruling is yet to come and there is still time for advocacy. Throughout my fellowship, there were many groups, in addition to corporation owners, who expressed opposition to the reform. Unfortunately, many fewer groups who have benefited, or will benefit, from this reform have shown their support.

My experience with medical associations during my year on the Hill was that, unfortunately, each organization focused on its special interests, perhaps assuming others would advocate for the general issues. This was most evident last spring, when only one medical association’s representatives voiced dissatisfaction with the block grants and overhauls of Medicare and Medicaid proposed in Representative Paul Ryan’s plan. When asked about it, other associations’ groups said they were not in favor of this plan, but they didn’t bring it up and it was not included in the talking points outline in the organization’s packet. It is important for AMA members to be both informed and vocal about key issues, such as the following.

The sustainable growth rate (SGR). The Balanced Budget Act of 1997 established that the yearly increase in Medicare payments per beneficiary cannot exceed the annual growth of the gross domestic product (GDP). If the rate of the Medicare increase is lower, then payments to clinicians and hospitals can be increased in the coming year; if it’s higher, payments must be decreased. Congress has stepped in repeatedly over the years to prevent reimbursement rates from being lowered, which is called the “doc fix.” This was last established in the Medicare and Medicaid Extenders Act of 2010, which continues through January 2012. Although providers have not yet had to accept lower fees, in some cases extending legislation has occurred after the reduction date, and the difference has been paid retroactively. There is considerable fear in the months leading up to each of the deadlines that there may not be another “doc fix.”

Limiting Medicare and Medicaid. This year’s congressional budget resolution would limit federal funds for Medicare and Medicaid. The Path to Prosperity proposal (also known as “The Ryan Budget”) would alter Medicare and establish premium payments to seniors of $8,000 per year to subsidize their private health insurance. This voucher would completely alter the way many Americans receive care. The private insurance would probably have copays, caps, and preauthorization requirements—all of which would effectively prevent seniors from receiving care and clinicians from giving it. In 2012, the proposal would block-grant federal funds for Medicaid to states, which would regulate the Medicaid program themselves. It would not be long before we saw “creative” state plans aimed at curbing costs by refusing services to some of our most vulnerable patients.

Accountable care organizations (ACOs). The ACA laid the ground work for the creation of ACOs to improve care by encouraging more communication between providers and subspecialists and reducing duplication of services. Payments to ACOs, through the Medicare Shared Savings Plan, will be dependent on measurable benchmarks and based on improvements in health outcomes. ACOs remain an enigma to many but are currently being evaluated in trials.

Whether you are a supporter of health reform or have your apprehensions about it, I encourage you to stay informed and begin, or continue, to advocate for your patients and yourself. Here are some ideas:

• Ask yourself: how will proposed changes affect my patients and my ability to function as a doctor? You have a voice as a constituent as well as a member of a health care-related organization.
• Join or continue your memberships with professional organizations that have a strong focus on advocacy.
• E-mail or call your local, state, and federal representatives to voice your concerns. Each representative has a web site, and they are easy to contact. In addition, professional organizations will have a script for you (usually 3-5 sentences) to use about the topic, if you prefer. Offices receive hundreds of calls and letters each week but they do tally correspondence and take your opinion into account.
• Organize visits with your representatives in your home state. August recess is a great time to meet with members of Congress, as most of them are in their districts for an extended period of time.
• Plan a trip to Washington D.C. Most organizations have at least one advocacy day each year, generally during the spring, when the weather is nicer and there is more discussion about the budget. You can attend one of those events or call the representative’s office and visit on your own (although there are advantages to being part of a group).
• Many members of Congress set aside at least an hour a week to meet with constituents in an open forum. This usually takes place in the morning before Congress is in session for the day and involves 5 to 10 minutes with the representative, additional time with his or her staffers, and a photo opportunity. This is relatively informal, and families are welcome to attend.
• Encourage your patients to speak up and let their voices be heard, either individually or as members of an organization.

Too often we remain silent on issues that could have major impacts on patients and our livelihoods. I encourage you to change and be as vocal with your support for health care reform as others are with their dissatisfaction.