AMA's Moving Medicine video series amplifies physician voices and highlights developments and achievements throughout medicine.
Kicking off 2022 with the AMA's "Look Forward/Look Back” series, AMA Chief Experience Officer Todd Unger talks with Todd Askew, the AMA's senior vice president of advocacy in Washington, D.C., about the AMA’s critical work in advocacy this past year and what advocacy issues physicians should watch for in the months ahead.
Stay up to date on all the latest advocacy news by subscribing to AMA Advocacy Update.
- Todd Askew, senior vice president, advocacy, AMA
Unger: Today in our Look Forward, Look Back series we're joined by Todd Askew, AMA's senior vice president of advocacy in Washington, D.C., who will discuss AMA's critical work in advocacy this past year and what advocacy issues physicians should watch for in the year ahead. I'm Todd Unger, AMA's chief experience officer in Chicago. Todd, thanks for coming back. The AMA's advocacy team was very, very busy this past year, in the past few weeks alone in 2021, your team has helped divert a potential Medicare payment crisis and together with the American Hospital Association, brought a lawsuit to help protect physician payment and patient access to care on the surprise billing front. Looking back at 2021, what do you think was AMA's single biggest advocacy win?
Askew: Well, thanks, Todd. It was quite an end to the year but it was busy throughout the year. There was really no let-up from day one. And it's hard to say what is the one specific biggest advocacy success that the organization and the profession had given the breadth of things that were going on. There were a number of things with the new administration, taking things in a different direction, in many, many things that we very much supported and a lot of great opportunities were there and we took advantage of them. The ongoing effort to combat the COVID epidemic and the immense amount of work that all physicians put into it. The vaccination campaign, the new information that we were constantly learning about therapeutics and how best to treat patients. Huge advances in those areas.
And you mentioned a couple there right off the top, advocating for physicians, making sure that they have a fair shot with payers. For example, during the ... is part of the No Surprises Act but also continuing efforts on prior authorization, small victories can be big victories. And so small victories are a starting place. And of course, being able to stave off payment cuts here at the very end of the year. And a huge array of things it made possible by a great team here at AMA but also the deep, deep involvement of physicians across the country, of specialties, of state medical associations. It was just a tremendous, tremendous year of important items and accomplishments from January straight through the December.
Unger: Well, the two that you mentioned were really powerful moves at the end of the year. And now I'm going to ask you to kind of rewind all the way back to January, believe it or not, our first conversation at the beginning of the year we had in the background, two Senate runoffs in Georgia which could have largely impacted the direction of the Affordable Care Act. The ACA has had a relatively good year. Can you talk about where things stand and what progress was made to keep people insured in 2021?
Askew: Sure. Well, absolutely, one of the very first major actions or major pieces of legislation was the American Rescue Plan Act, which opened up access to Affordable Care Act coverage to many millions of more people, both through increased access to subsidies and other improvements to the program, on a temporary basis, because they could only afford to fund them for a certain period of time. But the result of that early action was that a couple of million people who were otherwise uninsured, especially during this time of great uncertainty, were able to access affordable quality insurance. And in fact, throughout the year, we've seen that the Affordable Care Act and their various coverage options provided by the ACA are now covering more people than ever, than in the history, in the decade plus history of the program. Something like 63% of those who are still uninsured have access to coverage.
So even those, we've basically cut the uninsured number in half with the ACA and more than half of those that are still uninsured have access to coverage under the ACA or through their employer that they could take advantage of today. And so we are getting down to more difficult populations to reach in terms of coverage, the largest being those who are undocumented and don't have access to Affordable Care coverage. The second largest group being those who have access, an offer of affordable coverage from the employer but have chosen not to take it. And then there's a couple of million Medicaid eligible persons who are in those 12 states that didn't expand Medicaid.
So the Affordable Care Act has really made a massive improvement in both this year with the increases but also over the life of the program, made a meaningful impact on the number of uninsured in this country. And then of course, early this summer, we had the Supreme Court dismiss the most significant and latest challenge to the law. And so hopefully we can move beyond fighting over the law in court and get back to making those final improvements that need to be made to kind of close that last stretch of people who don't otherwise have access to coverage.
Unger: Absolutely. That is a big accomplishment and good to see some of that uncertainty around that go away then. Well, speaking of uncertainty, a lot of us did think that 2021 was going to look a lot different. We started the year with the rollout of vaccines and our hopes, I think were to at least see the beginning of the end of the pandemic. It didn't turn out that way but the AMA's advocacy team continued to work there to protect and advance health care during the crisis. Why don't you talk a little bit about some of the many ways that AMA advocated for physicians in direct response to issues stemming from the pandemic?
Askew: So a lot of what we were working on is identifying those specific needs that physicians and physician practices had and trying to facilitate the federal government's attention to those needs. Many are the same that we've dealt with throughout the pandemic. Access to financial resources, to deal with the challenges of practicing in a more costly environment and also an environment where many patients are still concerned about coming into the health care system for some of their other needs. Continued access to PPE, I mean you're familiar with those challenges. And then we add on top of that, that opportunity for vaccination, but a lot of confusion right off the bat and a lot of trouble, very hard to ramp up a program and make sure that physicians’ offices have access to vaccines for their patients. We would certainly much prefer people be vaccinated with their primary care physicians so that that is part of their continuum of care.
Not always possible though as the program ramped up and there was just an imperative to move the vaccines out as fast as possible but we've gotten there. And now I think to see how widely vaccines are available throughout the country, I think is a testament to the entire health care system and really the miracle of how these vaccines were developed. Unfortunately, the need to educate the public continues and you just have reached this number where there are a set number of people who for whatever reason and reasons vary, whether it's misinformation or fear or another reason, just do not want to be vaccinated and so we need to continue to work with physicians, with hospitals, with other health care providers, with the government, with employers, with unions, with everybody to get those last people vaccinated because vaccination is the way out of this.
And the AMA has really worked very hard to support physicians and to support the health care system in promoting vaccination as the way we are going to get beyond this phase of COVID and into a place where we can more easily deal with this disease in a less dramatic way, if you will, than we have to now with these waves and potential for new variants. And so we've continued to work very closely with the government to facilitate the physicians needs being met, whether it's payment for vaccine administration or other resources. And so ongoing struggle, it's been gratifying very much to see how physicians have stepped up to pursue this effort. And there's still a lot of work to do.
Unger: Todd, one of the big changes in 2020 when was this rapid emergence of telehealth. And as we enter 2021, the challenge was a little bit different, which was really kind of trying to preserve that progress. Why don't you talk a little bit from an advocacy standpoint, how telehealth has progressed this year and what you've been working on?
Askew: So telehealth, I mean, we say it frequently but it is one of the few bright spots of this entire experience that we've lived through over the past almost two years now, physicians who may have previously been reluctant to embrace telehealth, certainly payers were very reluctant to support telehealth, including Medicare, which had a very, very limited opportunity for people to participate in telehealth, really embraced it as a necessary ingredient to triaging patients and also providing ongoing care for people's health care care needs that could be handled outside of coming into the hospital or coming into the doctor's office. A lot of the care was able to be provided that way. And a lot of unnecessary exposure was avoided. The value of telehealth has really been proven.
The data is pouring in and we continue to collect it. Unfortunately this is, as you referenced, a temporary state, at least for the Medicare program in that the statutory requirements for coverage are very limited. And this expansion is only applicable during the public health emergency. Now we do expect unfortunately, the public health emergency declaration to continue well into 2022 but policy makers, particularly on Capitol Hill have now completely realized the value the telehealth brings to the health care system and are searching actively for a way to preserve as much of it as possible. Recent rulemaking has opened some additional avenues for limited coverage, particularly in the behavioral health arena but a lot more needs to be done. And statutory changes are going to have to be enacted probably not until next year, hopefully next year, in order to preserve this option for beneficiaries beyond the public health emergency time. So it has proven its value. Now we just have to find the pathway and the resources within Congress to make it a more permanent part of our health care system.
Unger: Todd, one of the issues I've also had a chance to talk with your team about and something that has really been another thing that's suffered because of the pandemic is the national overdose epidemic. It continues to be a huge challenge this year. This is something the AMA has been fighting for many years. What do you see in 2021 as the major developments here?
Askew: Well, I think that the fact that we were making progress and really had a setback in terms of disruption of treatment, lack of opportunity to get people into treatment, taking their eye off the ball has had a detrimental effect, one significant shift that we have been seeing for years. And now it's extremely pronounced is a shift away from just the finger pointing at overprescribing and legally prescribed substances as the source of the epidemic. A shift now more towards, greatly towards illegal, illicit fentanyl and other analogs as the root of most of the overdose epidemic, other drugs, being laced with these substances. And that is what is driven, just the great majority of the increases in overdose deaths. And so we have to shift our mindset a little bit beyond just overprescribing as the root cause here.
And we need to look at the illicit drug trade, where these drugs are coming from and most important how can we ... The only way to combat this, one of the most effective ways is treatment, easier access to treatment, more opportunity for people to get into treatment without jumping through so many hoops, more opportunity for more people to provide treatment and also data. We need more information to better diagnose the problem and identify solutions. And it feels like we're back at step one. We're not, you look behind us and so much has been accomplished but the challenge is still immense and it's going to continue to be a significant part of our efforts for the next year, for this year but for probably for some time to come.
Unger: So speaking of looking ahead to 2022, what do you see as the greatest opportunities for the AMA to make a difference with its advocacy efforts?
Askew: Well, you've referenced telehealth, which I think we have a tremendous opportunity to promote and improve access to telehealth for all patients. And so I think that's a tremendous opportunity. I look at Medicare payment, every year it's the same battle, it's scrambling to stave off cuts. These cuts were particularly severe but every year it's fighting to stop a 2% cut, a 3% cut and it always has to get done at the end of the year. There's no stability, there's no predictability. The program increasingly the way the payment structure is designed under MIPS, the four separate programs, which aren't really aligned, doesn't make any sense. The opportunities for engaging in alternative payments models to some extent they're there but really the promise, the opportunity that was presented with this new payment model has never been realized.
The promise of MACRA, I mean, has never really come to fruition in terms of making those models available. So we need to step back. And I think a lot of policy makers who went through this experience with us at the end of 2021 are firmly aware of that and understand the need to fundamentally re-look at this. We have a number of problems that are built into the system that we need to address. One is budget neutrality. The way it's set up is sure we can provide increases for a particular service or set of services or type of provider but those increases don't come with new money. Budget neutrality dictates that payments for all the other services us have to be reduced. So we're dealing with this fixed pie that over the last 20, 25 years, inflation has greatly eroded the value of those services. And they're becoming increasingly difficult to provide at the funding levels that are available.
So that's one challenge that has to be overcome. Another is the fact that in statute, there are no updates. Most other providers under Medicare have built in updates that have some relationship to the increase in cost of providing the services—a medical economic index or inflationary growth—that is not present in the physician system, which is a legacy of multiple experiments of different systems and action taken to avert a massive cut a decade ago. So we have to pull together as a profession and come to some agreement and some ideas on how we can address these issues, how we can rebuild the payment system in a way that provides sustainable, predictable and payment rates that reflect the increasing costs of providing care while at the same time, incentivizing quality and making sure that physicians have the opportunity to engage in innovative payment models or ways of delivering care that are focused on their patients and not focused on a checklist of things that you have to do or some sort of metric that the whole purpose is to meet that metric.
So I think it's going to be a huge challenge but it's a huge opportunity. I think the time has come. I think we have been speaking with leaders across the Federation of Medicine and I think there's enthusiasm and a strong agreement that we need to sit down together and come up with a new way of doing this. And so I think that's the greatest opportunity that we have in 2022. It's not going to be a slam dunk and it's not going to be done in one year but if we're going to start on this journey, we've got to sit down and get going and this is the time to do it.
Unger: Absolutely. This last question, I don't think there's ever been a time when it mattered more to hear from physicians. We've got a lot of sources of misinformation out there. It's time that we try to make physicians the loudest voices in the room. The advocacy team has worked really hard on amplifying those physicians voices. How does a physician get more involved in advocacy in 2022 on all these important fronts that you've just outlined?
Askew: Sure. Well, I think the end of this past year in the effort to get Congress's attention and to stop a nearly 10% Medicare cut is a tremendous example of the power of physician voices that came together quickly. I mean, we'd been working it, laying the groundwork for a very long time but even just a few weeks before that effort came to fruition, there was little ... many policy makers felt like, well, we may be able to help a little but we're not going to be able to eliminate the entire cut. And the Physician Grassroots, both the AMA's Physicians Grassroots Network, as well as work across the Federation of Medicine, work with the state medical associations, just came alive and they lit up the phones and they lit up social media and they lit up the email boxes and got their attention and the voices of physicians, all they have done, all they have been through, I think have grown even more respected and more admired by policy makers over the last couple of years.
And so through the AMA Physicians Grassroots Network where people should please go to, I believe it's PhysiciansGrassrootsNetwork.org. And I think you can probably put that up, sign up. We won't flood your email with information but for us to be able to call on you and for you to hear from us when it is most important that you reach out, it's just such a tremendous asset that we have and why it's such a privilege to represent a group of individuals who is so well respected and so a knowledgeable about the challenges facing their own profession.
And then also the AMA's Advocacy Update. You can subscribe to that on the AMA's website. Twice a month, we provide information to keep you up to date with current and upcoming challenges in the public policy arena so you can and weigh in but also just so that you'll be knowledgeable and ready to weigh in when the opportunity arises. So those are two great ways that people can get involved. I would also be remiss if I didn't encourage people to become active politically through AMPAC in the political process also helps your voice and our voice be heard as well. So lots of opportunities speak up and they are hungry to hear from you.
Unger: The power of those physician voices really matters. And with the AMA to act as a unified voice for medicine and for patients. Again, I encourage you to check out PhysiciansGrassrootsNetwork.org and also sign up for the AMA Advocacy Update at ama-assn.org/advocacy-news. That wraps up our Look Forward, Look Back episode on AMA advocacy. There's a lot to cover. Thank you, Todd, to you and your team for the work that you've done throughout this year and with our federation. We'll be back soon with another Moving Medicine video and podcast. Be sure to click subscribe on the AMA's YouTube channel, Apple, Spotify or wherever you listen to your podcasts or find all our videos and podcasts at ama-assn.org/podcasts. Thanks for joining us. Please 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.