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CHICAGO -- During an open forum on healthcare reform at the American Medical Association's , AMA leadership on Saturday called on physicians to forge relationships with lawmakers and protect their patients access to care.
Richard Deem, the AMA's senior vice president for advocacy, said the group could not square the American Health Care Act with the AMA's own policies. Knowing 23 million more people would become uninsured through the new bill -- according to the most recent Congressional Budget Office's estimate -- the group could not support it.
Deem encouraged AMA members in the audience to work with lawmakers on both sides of the aisle and urged physicians to tell their stories.
"There's a lot of people who can work through the policy details, but you are on the front lines. You see what the outcomes are for patients with insurance, without insurance ... addressing medical needs early and what happens when that doesn't occur. I think if you tell those stories to your members [of Congress] they've a better idea of the consequences. You've got to put a human face on this," he said.
When the focus is only on the numbers, the end results are "cold decisions," he continued.
Every year reporters write about the masses of people lining up to receive care at a free annual clinic in southwest Virginia. And every year, due to the sheer volume of demand, people are turned away, he said.
"It'll make you cry and it should make you cry," said Deem.
"We can do better in this country than to make sure that you are not just waiting once a year for a free clinic," he said to broad applause.
In addition to joining AMPAC, the bipartisan political action committee, and attending town halls and smaller closed forums, Deem and Andrew Gurman, MD, the hand surgeon who is completing a term as AMA president, stressed the need to get to know members of Congress.
"You can't just walk in having never been seen before and say, you've got to get rid of this [bill]," said Gurman. "What you need to do is develop relationships so you can walk in and tell stories to someone who knows you as a reasonable person and will listen to you."
In addition to calling for physicians support in the battle to keep the ACA, Deem reviewed the current House bill's status and the next steps in the GOP's process.
The AHCA, which passed in early May, has moved to the Senate where Republicans in that chamber have stressed that their version of a repeal-and replace bill will differ, he said. He noted that Senate Majority Leader Mitch McConnell (R-Ky.) is operating outside of the usual committee process and is meeting members behind closed doors.
The Senate's goal is to present legislative language to the Congressional Budget Office on Wednesday, he said.
Most important in the Senate bill will be the tax credits and its Medicaid provisions.
The Senate is under pressure to provide richer tax credits than the House-passed bill in order to improve individuals' ability to afford health insurance. Whereas the Affordable Care Act based tax credits on individuals' income, the House bill links them to age.
Some members of Congress including Sen. John Thune (R-S.D.) are working with colleagues to find ways to make it easier for people to purchase private insurance, he said.
However, just lowering premiums won't help patients, if a plan's deductible is too high and the plan skimps on benefits.
Medicaid
Medicaid, meanwhile, is financed through both state and federal contributions with poor states receiving a higher percentage of funding from the federal government -- through a formula known as the . Under the ACA, states that expanded Medicaid initially received an FMAP of 100% for the newly enrolled expansion population, tapering to 90% by 2020.
The House-passed bill recommends a two-year phase-out period, but the Senate appears to be discussing a "softer landing" said Deem, potentially involving a 3-, 5-, or 7-year transition. However, he said that some states have included language in their own programs to invoke an "automatic exit" from expansion.
But the House-passed bill goes beyond just repealing the expansion and seeks to overhaul Medicaid's underlying financing structure. Instead of functioning as an entitlement program where anyone who is eligible can receive its benefits, the GOP recommended strategy of implementing per capita caps would provide states with a set amount of money based on the population it covers and then adjusts that funding based on medical inflation.
However, such a formula is unlikely to keep up with the costs of medical innovation. For example, much like the discovery of direct acting antivirals for treating hepatitis C, if a similarly effective but expensive drug for another common condition became available, state budgets might tighten as a result.
Moreover, while states may not notice a pinch in budget in the first year or two, Congress has the ability to tighten the per capita cap formula and reduce its support, making it harder to find savings in future years, Deem said.
Essential Benefit Waivers
Lastly, Deem addressed the issue of waivers for states. Under the AHCA, states would have the option to scrap the ACA's 10 essential health benefits. The Senate version of the bill might also include such waivers, which could affect even privately insured patients since it would allow lifetime and annual limits to be reinstated.
Asked during an open forum whether there were changes that could be made to the AHCA to win the AMA's support, Deem was skeptical.
"The big driver here is a political promise to repeal the Affordable Care Act," he said. The House achieved that mostly by repealing the taxes on high-income people that fund subsides for the less affluent.
If the premise of the bill had not started with repeal, and instead focused on creating a better health system, the AMA could have recommended plenty of changes -- such as the tax treatment of insurance -- but that isn't what the bill aimed to do, he said.
Gurman and Deem were also asked why the AMA hadn't put forward its own legislation, Deem responded that such actions were neither "conducive" nor "productive" in the current political environment. Again, he reminded the audience that the current bill's goal was to fulfill a campaign promise.