When one thinks of the repeal of the Affordable Care Act (ACA), the major tax and coverage provisions required by insurance come to mind. Efforts by the new Trump Administration and Congress to repeal the ACA will obviously have a tremendous impact on these features of the law.
What is less known is other provisions of the law, many of which have an impact on academic family medicine–they affect workforce or primary care research, or both. These issues do not have large constituencies behind them–we may be alone or in slim company trying to maintain key portions of the law that impact our academic infrastructure.
Academic Primary Care Provisions in the Affordable Care Act
- Establishment of payments for training provided to Teaching Health Centers, rather than hospitals
- Reauthorization of Title VII Primary Care Training and Enhancement with an emphasis on the patient-centered medical home
- Primary Care Extension programs to assist primary care practices regarding innovations and best practices
- Medicare Graduate Medical Education (GME) provisions supporting community-based training within the confines of historic GME
- Establishment of the Patient-Centered Outcomes Research Outcomes Institute (PCORI), to improve patient care and outcomes through comparative clinical effectiveness research
- US Preventive Services Task Force (USPSTF) gained a new requirement that private insurance plans cover recommended preventive services without any patient cost-sharing
A Campaign We Must Not Lose
Assuming others will make the case for us is not an option. Working in partnership, STFM and the other CAFM organizations, along with our members, will need to actively engage on our key issues. If each of us does not get involved, we may not have the political might to support our position(s.) We do not have the luxury of large population size to assume that others will make the case for us. Members of Congress need many voices educating them about what we know–that the overall health of a population is directly linked to the strength of its primary health care system and workforce. They need to hear why each of these provisions is important to the primary care infrastructure of the United States.
It’s not news to you that we are navigating the unknown right now. While we know some of the issues that we can expect to be brought up during the repeal and replace process, we can expect many more that will be new and may need our attention. We need to be vigilant and responsive to new issues as they arise, determine how they may impact us, and pivot as needed to focus more energy around them, rather than perhaps some current issues. For example, the importance of science and the collection of health related data may be vulnerable. We will need to be aware of the need to prioritize and concentrate our efforts on key academic areas and support the AAFP and others on their more global efforts.
As I write this I realize many of us have strong feelings about the more global effort –not just regarding repeal of the ACA, but of Medicare and Medicaid reform, and more broadly beyond the health care sector. I am not suggesting you halt your advocacy efforts on these issues; I am suggesting that you expand your efforts specifically to the academic family medicine infrastructure provisions we all care about.
There is one additional caution I think is important to keep in mind as we navigate this wild Congressional session. It is probable that any vehicle moving forward, such as budget reconciliation, CHIP reauthorization, etc. will have provisions included that we do not support, and potentially the bulk of the provisions may be items we don’t support. However, if those are the only viable vehicles, and republicans have the numbers to pass them, we will need to work to include our issues as part of those vehicles.
Unlike our efforts during the passage of the ACA where we supported the underlying law, I don’t expect that this time we will. Strategically, we will need to move forward to try to incorporate our issues into final legislation that we may not wish to support.
A Snapshot of Options for Repeal and Replace
How will these provisions fare in the coming months? A great deal will depend on which version of the repeal holds sway. There are at least 7 versions of repeal (some with replace, others just repeal) available to legislators–with more being introduced at a fast pace. Several are actual bills that have been introduced already this year, or were available in the last session of Congress, such as H.R.277, the American Health Care Reform Act of 2017, introduced this year by Rep. Roe (R-TN,) who co-chairs the GOP Docs Caucus, and H.R.3762, last year’s budget reconciliation bill that was vetoed by President Obama. Others are statements of principle, proposals that would need to be fleshed out in legislative language, such as the House republicans’ A Better Way, published last June by Speaker Paul Ryan (R-WI), and efforts by the Heritage Foundation. Of note, some would repeal the ACA–the Patient Protection and Affordable Care Act of 2010–in its entirety, while others would repeal only the tax and insurance provisions mentioned above, and lately there is some possibility of allowing states to decide whether to maintain the ACA for their state. It is not the ACA alone that will be up for discussion: Medicaid reform, Medicare reform, the reauthorization of the Children’s Health Insurance Protection (CHIP), and more are in queue, several as part of the repeal, but others in terms of “replace.”
The use of budget reconciliation as the vehicle to move repeal forward argues for a more limited approach. Budget reconciliation is a mechanism where the Senate can move legislation by a simple majority (51 votes) rather than risk the use of regular order where filibusters are allowed and a 60 vote majority is needed. Some of our issues are in more clear danger than others due to the technical mechanics of using a budget reconciliation process to repeal the ACA. Yet, even with this approach, we need to keep in mind the forces aligned to change our health care system in this country.
We must take action–each and every one of us.
If you haven’t already, please take a moment to respond to the alert you received on the 19th; then keep up the conversation. Continue to raise these issues with your legislators and their key staff members. We will send out more alerts as issues require it–please keep an eye out for them. This is a campaign we must not lose.