In a tumultuous 2017, gains made to expand insurance coverage were threatened by various legislative and executive actions. Physicians responded with a strong voice in favor of proposals to stabilize the individual insurance market and against plans that would lead to millions fewer uninsured. Here is how AMA Wire® covered these vital developments. (You can also track the course of the AMA’s 2017 health reform advocacy with this comprehensive timeline.)  

Repeal of ACA individual mandate tax penalty would raise uninsured rate. In the fall, Congress shifted its focus from health reform to rewriting the federal tax code and repealing the penalty for not obtaining health insurance was being considered in the mix of proposals. The Congressional Budget Office (CBO) estimated this would lead to 4 million fewer people insured in 2019 and increase to 13 million by 2027. The mandate keeps a sufficient number of healthy people in the insurance pool to help spread the financial risk of illness.

The AMA joined the American Academy of Family Physicians (AAFP), American Hospital Association (AHA), Federation of American Hospitals (FAH), Blue Cross Blue Shield Association (BCBSA) and America’s Health Insurance Plans (AHIP) in warning Congressional leaders about the dire consequences this could have.

“Repealing the individual mandate without a workable alternative will reduce enrollment, further destabilizing an already fragile individual and small group health insurance market on which more than 10 million Americans rely,” the joint letter states.

It was a variation on the message the AMA had been advocating the whole year.

“Health system reform is an ongoing quest for improvement.” That statement was part of a Jan. 3 letter to Congressional leaders from AMA Executive Vice President and CEO James L. Madara, MD.

“The AMA supported passage of the ACA because it was a significant improvement on the status quo at that time. We continue to embrace the primary goal of that law: To make high quality, affordable health care coverage accessible to all Americans,” Dr. Madara wrote. “In considering opportunities to make coverage more affordable and accessible to all Americans, it is essential that gains in the number of Americans with health insurance coverage be maintained.”

As the new Republican president began to target health care reform as a top priority, the AMA presented the elements of its key reform objectives in an effort to shape the debate and legislation:

  • Ensure that individuals currently covered do not become uninsured and take steps toward coverage and access for all Americans.
  • Maintain key insurance market reforms, such as pre-existing conditions, guaranteed issue and parental coverage for young adults.
  • Stabilize and strengthen the individual insurance market.
  • Ensure that low/moderate income patients are able to secure affordable and adequate coverage.
  • Ensure that Medicaid, CHIP and other safety net programs are adequately funded.
  • Reduce regulatory burdens that detract from patient care and increase costs.
  • Provide greater cost transparency throughout the health care system.
  • Incorporate common sense medical liability reforms.
  • Continue the advancement of delivery reforms and new physician-led payment models to achieve better outcomes, higher quality and lower spending trends.

The ACA’s impact by the numbers: 20.4 million more insured since 2010. That was the figure provided by the U.S. Census Bureau. In February, the Department of Health and Humans Services’ National Center for Health Statistics released findings showing that the nation’s adult uninsured rate had fallen to an all-time low: 12.3 percent.

House ACA replacement bill would reverse coverage gains. The AMA announces it cannot support the American Health Care Act (AHCA) because it does not align with AMA health reform objectives. In addition to the loss of coverage, the AMA was concerned about the bill’s proposed rollback of Medicaid expansion, repeal of the Prevention and Public Health Fund, and prohibition against federal funds used for covered services provided by Planned Parenthood-affiliated physicians.

Senate urged to chart a different course. The House passed the AHCA over the AMA’s objections and without taking the AMA’s input. Senate Finance Committee Chairman Orrin Hatch, R, Utah, asked the AMA and other stakeholders for their ideas on taxation, health savings accounts, Medicaid, tax credits for buying health insurance, and funding to stabilize state marketplaces. The AMA responded with specific proposals, including:

  • Fund cost-sharing reductions (CSRs) for 2017 and 2018.
  • Provide monthly tax credits of about $50 for young adult to boost coverage rates and balance risk pools.
  • Help those with high deductibles by “modestly” funding health savings accounts.
  • Encourage states to decrease Medicaid administrative burdens while using new payment models to promote efficiency and high-quality care.

“Bottom line: 23 million people lose coverage.” As the Senate worked on its own bill, the 2017 AMA Annual Meeting was convened. The day before the opening of the House of Delegates (HOD), AMA Senior Vice President of Advocacy Richard A. Deem recapped what the CBO had to say about the AHCA. The next day, he gave an assessment of where things stood. “We are at a crossroads here,” Deem said. “Are we going to move forward and fix some of the problems with the ACA, or are we going to retreat on some of the goals we set for improving health care for the nation?”

“Our AMA opposes caps on federal Medicaid funding.” The AMA HOD adopted a new, unambiguous policy at the Annual Meeting to let Congress know exactly where physicians stand. “Capping Medicaid funding would be disastrous for patients, by limiting medical responses to unforeseen events and medical innovations,” AMA Trustee Carl A. Sirio said. “Caps would threaten coverage for vulnerable populations—especially children and those in need of a safety net—a point we have made repeatedly to policymakers in Washington.” The HOD would reaffirm the policy in November at its Interim meeting in Honolulu.

Putting a face on the 23 million people who would lose their insurance. After the Annual Meeting, the AMA travelled to Cleveland; Reno, Nevada; Denver; and Charleston, West Virginia. There they joined with the American Cancer Society Cancer Action Network, AARP, March of Dimes, the American Heart Association, the American Diabetes Association and local health care organizations to tell the stories of patients whose lives would not be the same if they lost their insurance.

“While Washington talks about people in aggregate—23 million people—the physicians of the AMA understand that those numbers represent the lives of real individual people, my patients: moms, dads, children, those who are sick, those who are hurting, those who need our help,” Dr. Barbe said at the Cleveland event.

“Ellie would have died.” The story of Ellie Wilkerson, a three-year-old with rhabdomyosarcoma, was told at an AMA co-sponsored event in Charleston, West Virginia. Ellie is one of the more than 180,000 people in the state who gained coverage with Medicaid expansion under the ACA. At the time of the event, the Senate was working on its latest ACA repeal-and-replace bill, the Better Care Reconciliation Act (BCRA) of 2017, which called for capping federal Medicaid funding. Resources on the AMA’s vision for health reform and how to contact Congress were assembled at the Patients Before Politics campaign website.

Calls for bipartisanship grow louder. Repeal-and-replace bills were defeated after high drama in the Senate chambers which included the return of Sen. John McCain, R, Ariz., who had recently been diagnosed with glioblastoma, and a tie-breaking vote by Vice President Mike Pence. If passed, the BCRA could have cost Arizona around $7.1 billion in Medicaid funding by 2026 and removed 400,000 Arizonans from Medicaid. McCain and Dr. Barbe both called for bipartisanship and return to regular rules of operation. Dr. Barbe repeated his call for addressing shortcomings of the ACA and achieving “the goal of providing access to quality, affordable health care coverage to more Americans.”

In the late summer, a bipartisan effort seeking to stabilize the personal health insurance market was started by Sens. Lamar Alexander, R, Tenn., and Patty Murray, D, Wash. But that was put on hold as Sens. Lindsey Grahm, R, S.C., and Bill Cassidy, MD, R, La., introduced another repeal-and-replace bill packaged as an amendment to the House-passed AHCA. The AMA opposed the plan.

“We urge all members of Congress to support the Alexander-Murray proposal.” The AMA extended its support to the bipartisan bill aimed at stabilizing the individual insurance marketplace in part by extending CSRs payments through 2019. The AMA also again co-signed a letter with the AAFP, AHA, FHA BCBSA, AHIP, and others urging Congressional leaders to maintain funding for CSRs. They noted the program directly benefits nearly 6 million low- and modest-income Americans.

A vote on the bill has not been taken. In addition to tax bill and individual-mandate repeal considerations; Congress must also reauthorize funding for the Children’s Health Insurance Program and the Teaching Health Center Graduate Medical Education program. A bill to repeal the ACA health care cost-cutting Independent Payment Advisory Board is also awaiting action.

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