Todd Askew discusses AMA advocacy priorities in 2021


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In today’s COVID-19 update, a discussion with Todd Askew, AMA’s senior vice president of advocacy in Washington, D.C., who shares an update on AMA's advocacy efforts and COVID-19 in the new year, including health care legislation.

Register for the State Advocacy Summit, Jan. 6-8.

Learn more at the AMA COVID-19 resource center.


  • Todd Askew, senior vice president of advocacy, AMA

AMA COVID-19 Daily Video Update

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Unger: Hello, this is the American Medical Association's COVID-19 Update. Today we're talking to Todd Askew, AMA's senior vice president of advocacy in Washington, D.C., will give us an update on the AMA's advocacy efforts and COVID-19 in the new year. I'm Todd Unger, AMA's chief experience officer in Chicago. Mr. Askew, we know this is a big week for Congress. I've got two Senate runoffs in Georgia happening today. We discussed briefly in November, but how do you foresee today's outcome affecting health care legislation, most notably the Affordable Care Act?

Askew: Well, thanks Todd. I think obviously, should the two democratic candidates prevail, you would have a Senate that's obviously much more receptive to President-elect Biden's agenda, including on the Affordable Care Act. I think it's important to remember though that 50 votes does not mean very much in the United States Senate when it comes to policy, that generally most issues must be decided by 60 votes. So it won't really be a carte blanche power for Democratic leadership in the Senate to enact President Biden's agenda. I do think, however, it does set the tone and it would create opportunity for some of those voices who may not have been heard over the last four years to be heard. Particularly, I look to control of the committees. The committee leadership sets the tone. They call the hearings. They choose the issues that the committees are going to address, and that's where legislation is born.

So, while it doesn't guarantee any potential legislative success, it does change the conversation and focus on different things that we may have been focusing on over the last couple of years. And that includes obviously, the Affordable Care Act. I don't think it's a guarantee. I think obviously, defeating the coronavirus is job one, two and three for the new administration. But certainly during the campaign, there's been conversation about the opportunity to make some further improvements to the Affordable Care Act. You can do a few things, even in a 50/50 Senate, but most policy would require a pretty substantial compromise.

AMA, of course, continue to strongly support the Affordable Care Act and a pluralistic health care system as a whole. So it's important that we, and hopefully the Senate, continue to work to strengthen the ACA, but also to support Medicaid, have a strong Medicare program, and have a strong private health care system as well, system of private health insurance that's responsive to the needs of the patients and lets them get affordable access to care and also treats physicians fairly. So there's a lot that could be done in the health insurance arena, for sure. But Republican control, Democratic control of the Senate by no means will define that opportunity.

Unger: Well, you mentioned combating the COVID-19 pandemic is kind of job one, two and three. President-elect Biden has indicated a stronger federal response to the pandemic after January 20th. How do you see the country's federal pandemic response changing in late January and February, and how will this help shape the AMA's advocacy priorities?

Askew: So I think it's important, first of all, that we remember we have one administration at a time. We have two weeks left in the current administration, and that's really an eternity in fighting this virus. And so we must continue to push and encourage the current administration to strengthen their efforts to encourage dissemination and administration of vaccines and promotion of public health measures, which could help keep people safe. So we'll continue to do that.

I don't see any doubt though, that a Biden administration will be more vocal in espousing the public health measures that we all need, that he's talked about, encouraging mask wearing, focusing on that first hundred days, encouraging people to wear a mask, increasing distribution of vaccines. A lot of that is going on right now, but I think you'll see a more vocal leadership. But I don't think they're going to lay it out right now. I don't think it would be appropriate for them to second guess at this moment what the current administration is doing. So I'm not surprised that we haven't seen a lot of details about what they would do. But I do know for a fact they're working very hard on it and this will be their top agenda item in the health care arena, as it should be once President Biden is sworn in on the 20th of January.

Unger: Well, in addition to the federal advocacy work, there's a lot of activity at the state level. And in fact, tomorrow kicks off the AMA's State Advocacy Summit. Can you tell us how has this year's meeting changed in light of the pandemic, and what do you hope will be accomplished over the next few days?

Askew: Well, I think obviously, the meeting's virtual, and so that's a first for us. But we have very strong registration. We have something close to 40 different speakers over the three days of the meeting. So I think we're going to have as robust and informative a program in the virtual environment as we have had previously in the in-person environment with this meeting. And obviously, there's a lot of important work to do for those who advocate at the state level. Most state legislatures have not been in session for 10 months. A lot of what's been done in the states has been done by executive order. So there is an immense amount of unfinished business. And we'll be talking about that as part of the State Advocacy Summit. We've got a lot of great speakers, including members of state legislatures to address these issues.

And COVID, obviously, will be one of the top issues, but we've got to start that conversation about how we rebuild and refocus the public health infrastructure. States play such an immense role in that conversation. Coverage, tele-health, all these issues, states play a very important role in. And then I would mention also the overdose epidemic, which has only grown during this period of shutdown and people being socially distant. We've seen a lot of that growth in these diseases of despair, and the overdose problem has unfortunately gotten worse. So we'll have a lot of opportunity to discuss those issues.

I would also mention that we'll be talking about how do you advocate in this environment where state legislatures, the meetings will be virtual still for the most part for the foreseeable future. And so how can advocates best engage? What tools are there to engage? What techniques can advocates use to press their case with their state legislators? And so we're looking forward to a great meeting. As I mentioned, registration's really strong. There's still time to register if people would like to. And I think it's going to be a really valuable experience for all the participants.

Unger: And you can find out more on an AMA site about that important meeting. Well, speaking of very hot topics, one of the very key issues over the past several weeks has been around surprise billing and the No Surprises Act. Mr. Askew, can you give us an update on what does it mean for physicians?

Askew: Sure. So at the end of the year, obviously, we had a large health care package come together, including COVID stimulus, the annual appropriations bills, this massive multi-trillion dollar package. And included in there was a priority that Congress has been working on for a number of years to deal with unanticipated medical bills. Of course, Congress started looking at this a number of years ago when there was a lot of focus on some really high profile instances. There was "The New York Times" story, I think, on an assistant surgery bill for $117,000. Things like that really focused Congress's attention. And so you look more at the problem. You look more at how this is happening.

And for various reasons, you had physicians who were not in-network practicing in hospitals that were in-network. And so patients would go and get care. And usually these were physicians, or other providers, it wasn't just physicians, who the patient really didn't have the opportunity to select, who would be their anesthesiologist or their radiologist, for example. And so I think everybody from the physician community agreed right off. The problem here was between the payer and the physician, that the payer was not offering fair rates. They couldn't come to an agreement. The patient was stuck in the middle. So number one priority was to get the patient out of the middle, and this legislative solution does that. But it's important to look back at where we started, in that some of the solutions that were being proffered a few years ago were horrible. They were going to just give the insurer the final word that whatever the insurer paid, that is what the physician was going to have to accept, which would have really meant why would an insurer ever offer a contract to these physicians if they can dictate what the payment is now?

There were other proposals to say every physician practicing in network hospital must have a contract with all the payers that that hospital does. Which again, if you're forced to have a contract in order to practice, then that puts the physician at extreme disadvantage. So we've moved beyond that. One of the key features, in fact the central feature that physician community was pushing, was a feature that was part of a New York law and other states have adopted as well. And that's an independent dispute resolution, where if the two parties to these disagreements couldn't come to a mutually agreeable resolution, they could go to an independent dispute resolution entity and that entity generally would consider a number of factors. It's a baseball-style arbitration where each party makes their final offer, and then the independent entity chooses the one that's most reasonable. So that's the basis of what was finally included in the legislation.

It's not perfect. We would very much liked to see physician charges be part of the consideration. That was not included in the final bill, because it would have really blown up the cost of the bill, according to CBO. However, importantly, the arbiter cannot consider Medicare and Medicaid rates or other public payer rates, we know are much lower than a fair market rate. So that's an important concession. And there's no threshold. Any claim can be brought to IDR. And so that's an important win, I think, propositions as well, in that it will help level the playing field for all claims, and hopefully give physicians a fair opportunity to negotiate a fair settlement while protecting the patient.

Askew: So, at the end of the day, there will be some regulation that has to come. It won't go into effect until 2022. And we will continue to pursue improvements as needed. But I think Congress and a lot of folks were happy to have this off the table because there's no real winners here. It's a lot of pressure on different segments of the health care system. I think they came to the best resolution that they felt they could right now.

Unger: Well, thank you to you and the advocacy team for all the work that you did there to benefit patients and physicians. You mentioned Medicare. On that topic, what about efforts to oppose cuts to Medicare payments? Was there any progress made on that at the end of the year?

Askew: Sure. In the final physician payment rule, many specialties saw significant cuts with estimated impacts on specialties that perform very few E&M services as high as 10% reduction in overall Medicare payments. And this grows largely out of the fact that we made some important improvements to evaluation and management services, not only to how those are documented, but also the rates that they are paid for those E&M services. And those were important improvements to the Medicare program.

CMS made additional changes related to that, additional codes and changes to other codes beyond just the E&M services. They really compounded the amount of spending that was shifting in one direction. And Medicare is essentially a budget-neutral system, so the cuts had to be made to the other side in order to balance the books, if you will. Luckily I think that Congress recognized that cuts of this magnitude, especially at this time when so many physician practices not only have suffered financially because of the COVID-19 crisis, but also continue to face financial pressures every day, as they are working on the front lines of providing care to COVID patients, the cuts would have had devastating impacts.

And so Congress stepped up and essentially proposed a one-time 3.75% increase in Medicare rates. They also delayed the implementation of the add-on code that was part of the reason of the cuts were so large. And there were some other things. Sequester was delayed for three months, so we'll going to have more time to work on that. So at the end of the day, some specialties will still see a small reduction in Medicare payment rates, but most will see an increase, and some a substantial increase in the coming year, which hopefully will help with making sure their practices remain viable in the near term, while we obviously continue to work for longer-term solutions to some of the Medicare payment dilemmas that we face every year.

Unger: Well, as we head into 2021, anything else that physicians should be aware of that's on the horizon?

Askew: Well, I think we're going to see, in the first few months of the year, obviously a continued focus on coronavirus and how we defeat this virus. And that's as it should be. Physicians need to continue to encourage their patients that when your turn comes for a vaccine, when it's available for you, to take it. And in the meantime, and even afterwards, continue to practice those good public health measures that we know, washing your hands, wearing a mask when you're in public, social distancing, not gathering in crowds. These are just the things we're going to have to do until we get beyond this. I think once we get a handle on this, things will really open up. With the new administration, a new Congress, I think there'll be a hunger for looking at some health care policies.

Obviously, we've got to look at the public health infrastructure. And obviously, we've also seen the disparate impact this crisis has had on marginalized communities. And it just has just laid bare a number of problems faced by those communities in accessing care, but also housing, nutrition, education, transportation, all those things that help people succeed and lead a healthy life. And so, I think there will be a lot of focus on those equity issues as it comes to health care, but also other aspects. And it's going to be an exciting two years, I think, in health care policy and legislation. But we've got to get over this first. We got to stay focused, press through to the end, get folks vaccinated and get this crisis under control. And then we'll see what opportunities open up.

Unger: Well, thank you so much, Mr. Askew, for your insights and perspectives and for representing physicians with a unified voice.

Askew: Thanks, Todd. Happy New Year.

Unger: For more information on the State Advocacy Summit. Make sure to check that out on the AMA site. Thanks for joining us. Take care.

Disclaimer: The viewpoints expressed in this video are those of the participants and/or do not necessarily reflect the views and policies of the AMA.