ACP LEADERSHIP DAY May 24, 2011

1. ACP LEADERSHIP DAY May 24, 2011 Moises Auron MD, FAAP, FACP HPPC Committee / CYP

2. Greg Rouan Arlene Fedorchak Mark Mayer Moises Auron Helen Koselka Paula Lafranconi David Dunbar Daniel Sullivan Ruchi Bhatia Hardeep Phull Shivani Jindal Kristin Gaffney Purvi Parikh Anubhav Mital Participants

3. Advocacy Groups

4. Budget distribution 41 % - Insurance (CMS, SSN) 24 % - Military 16 % - Other 12 % - Domestic discretionary 6.5 % - Interest on debt 0.3 % - TARP (Troubled Assets Relief Program) TOTAL: $ 3.7 trillion

5. Increased expenditure reasons Federal budget increases compared to 1981: Health programs (excluding Medicare and Medicaid) 480% Medicare 425% Social Security 121% Military 66% Income tax revenue 40% • www.washingtonpost.com/wp-rv/special/politics/30-years-spending-priorities-federal-budget-2012/

6. Revenue versus expenses

7. House GOP’s “Pledge to America” • Repeal and replace the ACA with: • Liability reform, insurance sold across state lines, HAS’s • Cover only 3 million more, leaving % of uninsured the same (CBO) • Cut $100 billion from non-defense discretionary programs and block any unspent stimulus dollars.

8. House GOP budget versus Obama

9. Both budgets will increase the federal deficit and debt http://www.washingtonpost.com/wp-srv/special/politics/dueling-budgets-2012/

10. What does all of this mean for ACP’s advocacy agenda? • Very tough legislative environment characterized by intense partisanship driven by ideology. • Drive to reduce federal spending and GOP opposition to the ACA will make it very difficult to get more money for health care, with discretionary health programs authorized by the ACA being especially vulnerable. • We are forced to play defense (protect key programs) rather than offense (asking for more government funding).

11. Our “asks” • Fix the Medicare payment system. • Fund key workforce discretionary programs. • Support effective implementation of “mandatory” programs to reform payments, improve quality and access, and “bend the cost curve.” • Improve the ACA by giving states more options sooner, by reforming the medical liability system, and by reducing “hassles” for doctors and patients.

12. Fix the SGR flawed system • Work for permanent end to cycle of Medicare SGR cuts, provide at least five years of stability--with higher updates for E/M services--during which physicians could earn more by voluntarily participating in pilots of new models (e.g. PCMHs) aligned with value to patients. - Stage 1 (CYs 2012-16): stabilize, improve, and engage in broad innovation, testing and evaluation. • Medicare would then transition to the new payment models found to be most effective during the pilot phase, with the goal to bring most physicians into the new models by end of the decade. - Stage 2 (CYs 2015-19) physicians transition to new payment and delivery models.

13. Key workforce discretionary programs • ACP request full funding at current authorized levels (as specified in the ACA) for: • National Health Services Corps • Workforce Commission • Title VII (Section 747) primary care training programs. • only federal support for primary care training and education.

14. Mandatory spending programs • The ACA includes essential programs to provide access to care for nearly all Americans, reform payment and delivery systems, and begin to bend the cost curve. Many of these programs are funded by mandatory dollars, meaning they don’t go through the annual appropriations process. • The only way that Congress can eliminate funding for these programs is to repeal the authority for them or prohibit agencies from implementing them.

15. What do ACP want legislators to do on mandatory programs? • Ensure continued implementation and dedicated funding for programs to reform physician payments, improve quality, and lower costs: • 10% Medicare primary care bonus program. • Medicaid comparability provision for primary care. • Center on Medicare and Medicaid Innovation. • Patient-centered Outcomes Research Institute.

16. Medicaid to pay no less than Medicare for Visits and Vaccines by primary care physicians (2013-14): Current ratio, Medicaid to Medicare, by state Source: Adapted from S. Zuckerman, A. F. Williams, and K. E. Stockley, “Trends in Medicaid Physician Fees, 2003–2008," Health Affairs Web Exclusive, April 28, 2009, w510–w519.

17. Making improvements in the ACA • ACP does not support repeal and replace, but believes that Congress can and should make improvements where it falls short. • Although it is highly unlikely that bipartisan agreement will be reached on the overall legislation, there already are examples where Democrats and Republicans have joined together to improve specific parts of the law, e.g. repealing the 1099 reporting requirement for small businesses.

18. What do ACP want legislators to do to improve on the ACA? • Co-sponsor the bipartisan Empowering States to Innovate Act, S. 248, H.R. 844, recently introduced by Senators Ron Wyden (D-OR), Scott Brown (R-MA), and Mary Landrieu (D-LA ) in the Senate and by Rep. Peter Welch (D-VT). • This bill would allow states to design their own ways to cover most residents, free of many of the law’s mandates (such as the individual insurance requirement) if they can offer comparable coverage to as many people, three years earlier than now allowed by the ACA.

19. What do ACP want legislators to do to improve on the ACA? • Co-sponsor the Patient’s Freedom to Choose Act (S. 312, H.R. 605), introduced by Senator Kay Bailey Hutchison (R-TX) and Rep. Eric Paulson (R-MN). • This bill would eliminate a mandate in the ACA that requires physicians to provide a prescription for patients who use their Flexible Spending Account (FSA) or Health Savings Account (HSA) to purchase over-the-counter (OTC) medication and repeals the $2,500 cap on contributions to FSAs under cafeteria plans.

20. What do ACP want legislators to do to improve on the ACA? • Support the Help Efficient, Accessible, Low-cost, Healthcare (HEALTH) Act of 2011 (S. 218, H.R. 5): Former Senator John Ensign (R-NV) introduced this legislation, S. 218, in the Senate, and Representative Phil Gingrey (R-GA) introduced this bill, H.R. 5, in the House. • The bill has been reported out of committee for a future vote by the House. • Would reduce the costs of defensive medicine by placing a cap of $250,000 on non-economic damages.

21. What do you want your legislators to do to improve on the ACA? • Introduce/co-sponsor legislation to Pilot Test Health Courts: Health courts, also known as medical courts, resolve medical liability cases through an expert panel of judges experienced in medicine and guided by independent experts, instead of lay juries. The health court model is predicated on a “no-fault” system, so that patients need not prove negligence to access compensation.

22. Uninsured Rate Among Adults Ages 19–64, 2008–09 and 2019 (with ACA) NH ME WA VT ND MT MN OR NY WI ID SD MI WY PA NJ IA NE OH IN NV IL WV UT VA CO KS MO KY CA NC TN OK SC AR AZ NM MS GA AL TX LA FL AK HI 2019 (estimated) 2008–09 NH ME WA VT ND MT MN OR NY MA WI MA ID SD RI MI RI WY CT PA NJ CT IA NE OH DE IN NV DE IL MD WV UT VA MD CO DC KS MO KY CA DC NC TN OK SC AR AZ NM MS GA AL TX LA FL AK HI 23% or more 7.1%–13.9% 19%–22.9% 14%–18.9% 7% or less Data: U.S. Census Bureau, 2009–10 Current Population Survey ASEC Supplement; estimates for 2019 by Jonathan Gruber and Ian Perry of MIT using the Gruber Microsimulation Model for The Commonwealth Fund. Source: Commonwealth Fund State Scorecard on Child Health System Performance, forthcoming 2011.

24. Mission accomplished!