Patient Support & Advocacy

Health care 2020: Here’s where Congress and the states are headed

A divided Congress and a presidential election year create impediments to passing meaningful health care legislation. But Todd Askew, the AMA’s new senior vice president of advocacy, believes there are still opportunities for bipartisan bills to pass.

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Helping in this regard is a May 22 deadline to extend funding for popular health care programs and the fact that, according to a Gallup poll, health care concerns such as cost, access and coverage were the top issues on voters’ minds in the 2018 midterm elections, and politicians want to be viewed as being on the right side of those topics.

During the recent AMA State Advocacy Summit in Bonita Springs, Florida, Askew noted that Washington gridlock opens the door for serious state-level health reforms.

Askew, the former AMA director of congressional affairs, also offered tips for physician advocates lobbying their legislators and he reflected on the legacy of his predecessor, Rich Deem, who spent 35 years at the AMA advocating for doctors and patients.

What should physicians anticipate on surprise billing legislation?

Askew: Election years are always a difficult time to move significant pieces of legislation. The issue of surprise billing, however, has received a lot of news media attention and has a particularly populist appeal and broad support among patients and employers that’s generated bipartisan interest given the importance of health care costs as a significant issue in the election.

So, I think certainly there will be a continued effort to advance surprise billing legislation, especially prior to a late May deadline for the enactment of other health care extenders. I think that we are making progress in moderating the legislation—making it more fair for physicians while still protecting patients. And so that would be the goal I have, that it's able to go before May 22.

What is the significance of the May 22 deadline?

Askew: There are several health care extenders that were passed as part of the fiscal year 2020 spending package, but they only run until May 22, and that is actually the hard stop before a congressional recess. So, it's kind of a forcing action for them to get something done. You'll also probably see an effort to include some sort of drug-spending legislation in that package sometime during the month of May.

The “extenders” include health programs that are constantly having to be reauthorized. They include things like the National Health Service Corps Scholarship Program, community health centers and the Teaching Health Center Graduate Medical Education program. These are good, popular programs that don't have a lot of controversy around them, but that Congress never seems to get around to passing longer-term authorizations. But they can also be a tool for Congress to drive other health care policies knowing that they must eventually pass legislation to extend these.

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What major issues are being stalled by congressional gridlock?

Askew: The biggest two right now are, obviously, surprise billing, which we continue to work on, and drug-price legislation, which has really run into barriers—both in the House and the Senate. The House passed its bill on a partisan vote. But that legislation doesn't stand much of a chance of being considered in the Senate.

On the Senate side, there is bipartisan legislation that Sen. Charles Grassley, [R-Iowa], and Sen. Ron Wyden, [D-Ore.], have introduced and reported out of committee. But it finds a lot more support among Democrats than Republicans, so Senate Majority Leader Mitch McConnell, [R-Ky.], is highly unlikely to put that bill onto the Senate floor with significant Republican opposition. I think that, if they find some sort of compromise to bring some more Senate Republicans on board, that there's a chance you could see legislation passed later this year. But there's a long way to go before that happens.

At the state level, what’s the status of prior-authorization reform?

Askew: Obviously, states can only regulate insurance products that are sold in the individual market or the fully insured market as opposed to those that are covered by the [Employee Retirement Income Security Act of 1974] ERISA, which can only be regulated by the feds.

There have been some states that have made significant improvements. One important example is Pennsylvania’s and other states’ prohibition of Medicaid prior authorization for medication-assisted treatment for opioid-use disorder. We've seen a growing amount of success across the country with states moving to prevent payers from requiring those extra steps for people who are trying to get into recovery.

How can doctors effectively communicate with policymakers on scope of practice?

Askew: In dealing with scope of practice, it’s important to be factual, to talk about the differences in education and training between different types of health care professionals. It's important to present data about the differences in outcomes or treatments provided by the different types of professionals. It's important not to be dismissive of their skills for what they are trained and licensed to do. And it's always important to emphasize the value of nonphysician providers as critical parts of the physician-led health care team.

I think folks will also hear that “physicians are just trying to protect their turf.” But I think that the data demonstrates real differences in the care provided. And, certainly, the differences in the education and training should be self-evident. Also, frequently you'll hear that “doctors don't go to the rural or underserved areas where nonphysician providers go.” But the AMA Health Workforce Mapper points out pretty clearly that all health professionals tend to practice in the same areas and there's not a glut of underutilized nonphysician providers in rural areas.

How do you channel younger physicians and medical students’ passion on issues such as climate change and gun violence into legislative or regulatory action?

Askew: I think the more passionate you are about an issue, the better advocate you can be. All of these are issues that the AMA is engaged in, one way or another. It's important to be realistic about what can be accomplished in the short term, but certainly the evidence is clear on the potential health impact of climate change, the impact of gun violence in the United States and the role of social determinants of health in the health challenges that so many people face. I would just encourage them to bring the evidence forward and advocate on those things.

If these issues bring medical students and physicians into the fold, how do you sustain their interest?

Askew: Once people get a taste for advocacy, a lot of people tend to fall in love with it. It's important that, just like anything else you do, you practice, repeat and stay engaged. Not necessarily calling every day, but trying to stay in regular contact with your legislators and their staffs about those issues. Staying abreast of the news and following up after your meetings are all important to remaining engaged in the long term.

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How should physicians engage with legislators when they don’t always see eye to eye?

Askew: It's unlikely you're going to find anybody that you agree with on 100% of the issues. If you need to work with someone on one issue, it's not worth dwelling on issues where you may disagree. It's important to find common ground and to see where you could work together on those areas where you agree or where your positions are close enough that you might find some common understanding.

If there's just a vehement disagreement, if you're coming from polar-opposite directions, make your position known. But it's not worth spending time on it—especially if you need to work with them on other things. You can disagree without being disagreeable.

Don't pick a fight with them or try to goad them into an argument about something that you already know you're not going to find any common ground on. It's a waste of time for both of you.

Lastly, you’ve taken over for Rich Deem, who—in his 35 years with the AMA—was recognized as one of the most effective lobbyists in Washington. Can you comment on his legacy and say what kind of advice he offered you?

Askew: Rich's legacy at the AMA and in health care policy in Washington over the last number of decades is substantial. I feel honored to be given the opportunity to be trusted to carry on those issues that Rich worked on for the AMA. Beyond any specific advice he may have given me, I think is his example—over the close to 20 years that I worked with him—his work ethic, his dedication to improving the health of America's patients and supporting America's physicians. That’s the part of his legacy that I got to witness every day for almost 20 years.

What’s your bottom line for 2020, then?

Askew: This is going to be a very challenging year, with a highly polarized electorate and sharply divided Congress. So, we have a lot of challenges ahead of us in this environment. But I think that, working in concert with other physician organizations and allying other aligned groups, we'll find a way to accomplish what we need to get done.