AAMC Reporter: December 2007

A Word from the President:
"2007 in Review: The Front Burner Issues"

If you were asked to name the "front burner" issues we faced in academic medicine this past year, which ones would you say occupied your attention? As I thought about this question, I recalled my many conversations with AAMC members, our governance, and staff over the year, as well as my meetings with thought leaders inside and outside the Beltway. Five issues—several of which are still in active legislative play as this column goes to press—repeatedly emerged as front burner, and one looms large on the 2008 horizon. See if you agree with my choices.

Funding for the National Institutes of Health (NIH)— For biomedical research, 2007 appears to be ending much the way it began, as an ongoing "hard landing." Just before Congress recessed for Thanksgiving, the House failed by two votes to override President Bush's veto of the Labor-HHS-Education Appropriations bill, which included $30 billion in NIH funding. Although representing only a modest increase over FY07 funding levels (3.1 percent), the proposed amount was a critical step toward at least stabilizing the nation's investment in this important public good. By the time you read this column, lawmakers will have returned to work on a revised appropriations bill that, even under the projected best case scenario, is expected to provide substantially less than what Congress had originally proposed.

Physician Workforce—With the largest number of medical school matriculants on record, more than three-quarters of our medical schools expanding or planning to expand capacity, and seven new institutions formally seeking Liaison Committee on Medical Education (LCME) accreditation, 2007 marked significant progress toward our recommended goal of increasing LCME medical school enrollment 30 percent by 2015. However, ensuring our nation's ability to address future health care needs now and in the future goes far beyond increasing the number of U.S. medical school graduates. Our 30 percent recommendation (concomitant with an increase in the number of residency training positions) would meet less than half the expected gap between supply and anticipated demand, and is therefore one of several strategies we should consider in tandem with other options, such as better coordination with other health professions and better evidence-based utilization of resources.

Medical School Tuition and Student Debt—Although 2007 was a banner year for medical school enrollment, rising medical school tuition and student debt remain formidable barriers for many aspiring doctors. According to this year's update of the 2004 AAMC report, Medical School Tuition and Young Physician Indebtedness, tuition and fees between 2001-2006 at private schools grew at an annual rate of 4.7 percent, and an astonishing 11.1 percent at public schools. Not surprisingly, the annual rate of increase of debt incurred by graduating medical school students rose more rapidly at public schools (6.9 percent) than at private schools (5.9 percent). Although these rates of increase have moderated somewhat in the last few years, medical school debt is rising at least twice as fast as physician income (which is growing at about 3 percent annually). If these trends continue, new doctors will be paying such a large portion of their after-tax income for debt services that the dream of being a doctor will become more and more out of reach for many Americans.

Medicaid Graduate Medical Education (GME) Payments—Another front burner issue related to the physician workforce is the fate of federal matching funds for state Medicaid graduate medical education (GME) payments to teaching hospitals. Earlier this year, the Centers for Medicare and Medicaid Services (CMS) proposed ending this critical support, leading the AAMC and other groups to seek and obtain a congressional moratorium on issuing a final rule until May 2008. The AAMC community remains actively involved in this matter, with bipartisan legislation extending the moratorium another year (until May 2009) pending in the House as this column goes to press. We are hopeful that lawmakers will take action on the bill this year, since their likely focus on the 2008 elections makes early spring passage a steep uphill climb.

Medicare Physician Payments—Similarly, we are collaborating with other members of the physician community to secure critical legislation that averts a 10.1 percent reduction in Medicare physician payments scheduled for Jan. 1. AAMC analyses have shown that for some institutions and specialties, the impact can be even greater than the average 10.1 percent change. Accounting for an estimated one-sixth of all physicians in the Medicare program, faculty practice groups treat a large number of Medicare patients, including many who require complex and highly specialized care. Clearly, reductions in Medicare physician payments will have a significant negative impact on faculty practice revenues, as well as the medical school missions that are supported by clinical income.

While each of the five issues I have discussed stood out in 2007, another issue promises to move to the front burner in 2008—health care reform. Many people with whom I spoke thought this year's highly partisan, often contentious battle over reauthorization of the State Children's Health Insurance Program (SCHIP) offered a preview of how access and coverage issues will play out in the 2008 presidential election, and especially of how we must overcome polarized politics in order to achieve the goal of enhanced access to health care.

What I think all these issues tell us is the importance of active engagement and involvement; whether it is advocating for NIH funding, understanding the complexity of the workforce issue, reducing financial barriers for future doctors, or salvaging key programs from political gridlock. With the 2008 campaign now swinging into full gear, medical schools and teaching hospitals cannot afford to sit on the sidelines. In my January column, I will discuss ways we all can become more actively engaged and involved in the new year.

Darrell G. Kirch, M.D., AAMC President and CEO

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