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A Word From the President: Leading Health Care Reform Beyond the ACA

AAMC Reporter: July 2012

Whether you agree with Chief Justice Roberts or the dissenting justices on the U.S. Supreme Court, we finally have clarity on the fate of the Affordable Care Act (ACA). The AAMC and the academic medicine community supported the law, both for the coverage it makes available to the vast majority of the nation’s uninsured and for the many ways it will accelerate the transformative work under way at medical schools and teaching hospitals to make care more accessible, more affordable, and safer.

But as the post-decision media storm subsides and the political posturing ramps up for November’s election, we simply cannot ignore the many daunting issues the ACA leaves untouched. While the law is a significant step forward, even its supporters agree the ACA falls far short of the comprehensive reform so many of us hoped for two years ago.

In this column, I would like to focus on the important work that remains unfinished and is necessary to improve the health of our nation over the long term.

While the ACA helps ensure that most people have health insurance coverage, it does not guarantee they will have access to care when they need it. The AAMC Center for Workforce Studies projects the United States will face a shortage of 90,000 physicians across all specialties by 2020 as the baby boom generation ages and our population grows. Another compounding factor is that, as people become insured, they are more likely to utilize health care services. A study of the Massachusetts health care system led by Nancy Kressin, Ph.D., last month showed that low-income patients were referred for 8 percent more elective surgeries after insurance coverage was extended to the majority of state residents.

Medical schools are doing their part to address physician shortages by increasing medical school enrollment 30 percent by 2016 over 2002 levels. But this expansion will not result in more practicing physicians until Congress lifts the cap on federally supported residency positions that it put in place 15 years ago as part of the Balanced Budget Act of 1997.

Another reality we must face is the well-documented link between poverty and poor health. A May study published in the Journal of Urban Health by Dr. Richard “Buz” Cooper and colleagues finds that health care utilization is greatest in neighborhoods that are poorest and least in the wealthiest areas. This work sheds important light on other studies of these variations that claim higher utilization is a sign of waste. The authors conclude, “Poverty is not only an unsustainable failure of social justice. It creates an unsustainable financial burden for our health care system.” To make long-term and lasting improvements in our nation’s health, we need to develop innovative approaches that improve care while reducing unnecessary utilization. The Camden Coalition of Heathcare Providers’ care management program that reduces unnecessary emergency department visits and improves care for residents of one of New Jersey’s poorest areas is one example of the kind of innovation taking root to address this problem.

As a nation, we need to confront how health care spending relates to other investments we do or do not make. We all know the United States outspends its industrialized counterparts by a wide margin on health care. A March 2011 BMJ Quality & Safety analysis by Dr. Elizabeth Bradley and others showed that the United States actually spends less on social services like rent subsidies, unemployment benefits, old-age pensions, and other programs aimed at improving and prolonging life. The findings demonstrate that nations spending more on health care delivery and less on social services, like the United States, have lower life expectancy and higher infant mortality rates.

Controlling health care costs will play a key role in putting our nation on a more sustainable fiscal path. The newest health expenditure data released by the Centers for Medicare and Medicaid Services show that the health care share of gross domestic product (GDP) by 2021 is projected to rise to 19.6 percent from its 2010 level of 17.9 percent. This means that aggregate health care spending in the United States will grow at an average annual rate of 5.7 percent for 2011 through 2021, much faster than the expected growth in GDP.

We simply cannot argue that this money, which amounted $2.7 trillion in 2011, is uniformly well spent when our outcomes are so poor. We rank behind nations that spend far less on health indicators, including obesity and infant mortality rates and life expectancy. And we suffer shameful disparities in outcomes across races, ethnicities, and geographic locations. The argument that we have the best care in the world simply cannot compensate for the fact that so many Americans are not getting appropriate care, or any care at all. We can—and must—do better.

Despite these harsh realities and the challenges ahead, it is important to remember that promising work is under way. During my visits to your institutions, I am privileged to see the many ways you are improving the quality and the efficiency of care, training new doctors to work in teams, and pioneering new treatments and bringing them to patients. In his book Good to Great, Jim Collins recounts the words of Admiral James Stockdale, who was a prisoner of war in Vietnam. To prevail in spite of great hardship, Stockdale said you must “retain the faith that you will prevail in the end, regardless of the difficulties, and at the same time, confront the most brutal facts of your current reality, whatever they may be.”

Much like the “Stockdale paradox” Collins describes, medical schools and teaching hospitals must confront the brutal facts of the shortcomings that will exist in our health care system even as the ACA goes into effect. At the same time, we cannot forget that the health of millions depends on us to “prevail in the end.” Aided by the ACA, I know our institutions and dedicated faculty are up to the task.

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