Vast inequities in health care. Millions of uninsured patients. The need to protect crucial funding for biomedical research. A growing physician shortage and bureaucratic obstacles to effective care. Maternal mortality, racism in medicine, and mounting public distrust of scientific sources.
All this and more drives the agenda of policy advocates who work to ensure that medical schools and teaching hospitals across the United States can provide patients with the best possible care.
Karen Fisher, JD, AAMC chief public policy officer, has been working on such efforts for decades. From legislative battles over the Affordable Care Act (ACA) to advocating for hospitals during the COVID-19 pandemic, she has influenced dozens of major policy matters. At the end of June, she is retiring from the AAMC.
Fisher first joined the association as assistant vice president in 1997 and spearheaded policy and regulatory efforts related to the special missions of teaching hospitals, including federal funding for graduate medical education.
In 2011, she left to serve as senior health counsel to the U.S. Senate Committee on Finance, where she was pivotal in enacting major Medicare reform — the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) — that repealed a damaging Medicare physician payment formula known as the sustainable growth rate and emphasized physician payments based on high-quality care.
In 2016, Fisher returned to the AAMC to run its Office of Government Relations. Since then, she has set advocacy priorities, navigated difficult political waters, and educated lawmakers about the pressing issues affecting some 250,000 U.S. medical trainees, 400 teaching hospitals, 155 medical schools, and the millions of patients that rely on them.
AAMCNews sat down with Fisher to discuss key legislative successes during her tenure and the work that lies ahead to promote the health of all.
What are the top five policy priorities for academic medicine now?
First, getting our teaching hospitals, patients, and communities through the pandemic is crucial. We need Congress to pass a supplemental COVID-19 funding bill, for example, to help fund additional vaccines and treatments. And we need legislation to ensure that the nation is prepared for the next pandemic. We have seen what happens when you have chronic underfunding for public health, for things like testing, identifying variants of a virus, and distributing vaccines, and we don’t want that to happen again.
There’s also ensuring that policy advances made during the pandemic continue permanently, such as changes to telehealth requirements. Previously, there were many obstacles to telehealth, including that it could only take place in rural areas. Loosened restrictions during the pandemic meant providers could help many more patients, and some AAMC members increased their telehealth services by as much as 200%.
The third issue is addressing the physician workforce shortage. Medicare is the primary public source of funding to offset the costs of medical residents’ training, and we need Congress to continue to lift caps on that support. This is crucial because the AAMC is predicting a shortfall of as many as 124,000 physicians by 2034.
Fourth, we need to ensure that policymakers understand the importance of providing increased growth in funding for the National Institutes of Health [NIH] so medical schools and teaching hospitals can continue crucial biomedical research.
Finally, we need to address issues of health equity and health care workforce diversity, so we can better work to improve the health of all. We need to advocate for data that identify social factors like housing and food insecurity that contribute to illness. And we want federal policies like the one that recently expanded Medicaid’s coverage of postpartum care to help address this country’s disparities in maternal mortality.
You mentioned NIH funding. Why is that so important?
Pretty much every medical advancement that we’ve had in this country started with NIH funding. The infrastructure for the mRNA COVID-19 vaccine was possible thanks in part to funding from the NIH over a decade ago. Researchers have revolutionized cancer care and created better treatments for diseases like diabetes and devised new techniques in organ and stem cell transplants, all thanks to NIH funding.
We’ve now had seven years of sustainable, robust growth in NIH funding. Before that, we had many years of flat funding. So we’re still barely at spending capabilities that we had 20 years ago, and we need to continue that trajectory. President Biden has indicated that kind of support with his Cancer Moonshot initiative, but we think there’s also a lot more wonderful research that could be funded.
How did the pandemic influence the AAMC’s policy priorities and the ability to promote those priorities?
In a lot of ways, the pandemic simply highlighted existing issues.
We’ve long known about health inequities, and COVID-19 highlighted them. We knew about the physician shortage, and the pandemic made that clearer. The pandemic highlighted the role of NIH funding since we were able to produce a vaccine in nine months because of prior funding. And we knew about provider burnout before the pandemic and that public health departments and the Centers for Disease Control and Prevention haven’t had enough funding, and that we needed expanded health care coverage. The pandemic just brought those issues to the fore.
As for our ability to advocate and talk to policymakers, Zoom was a big help. Congressional policymakers were working around the clock, so we were working around the clock. During COVID, three major pieces of legislation came out within a month that provided critical waivers and funding that enabled our teaching hospitals and physicians to provide needed care to COVID-19 patients.
Numerous issues affect the work of academic medicine. How does the AAMC decide what to prioritize?
We have a whole decision tree, and it has many questions. Do we have expertise to contribute? How important is the issue to health care systems and our patients and communities? What kind of role makes sense for us?
We also ask ourselves if we can join others who are advocating in similar ways. We’re big believers in coalitions. We convene a number of coalitions, including the Ad Hoc Group for Medical Research, which includes over 300 members committed to advancing funding for the NIH.
We also ask if this is the right time to address an issue. We care a lot about DACA [Deferred Action for Childhood Arrivals], for example, and often raise it with policymakers, but we also know immigration is not on the Congressional radar right now, so we monitor it and are ready to throw our weight behind it when the time is right.
Overall, we need to prioritize, but we also do need to recognize that academic medicine is involved in clinical care, research, education, and community issues. That means we have a responsibility to be active around a broad variety of health-related issues.
How can interested medical students get involved in health care policy work?
An easy way to get involved is through AAMC Action. It’s a grassroots advocacy group with 200,000 trainees, researchers, faculty, and physicians on call to address issues quickly. It gives you an avenue to connect with your legislators. It gives you information on issues and even model emails you can send to your legislator. Our member institutions also all have offices of government relations, so that’s another place to start.
The AAMC needs to be bipartisan in its policy efforts. Is that difficult?
I’m a strong believer that our issues are bipartisan.
Everybody cares about having a sufficient and high-quality physician workforce. Everybody wants research to help identify cures and advances to reduce disease and suffering. Everyone wants to ensure that when patients have complex health problems, there are places to care for them.
Sometimes, how legislators want to go about achieving those goals is different. But we’ve had open doors with both Democratic and Republican offices and good discussions with both. Each party has its own priorities. So sometimes we have to find a way to fit somewhere in their priority list, or we have to work harder to make the issues we care about get on their list.
Looking back, what do you consider some of the greatest policy accomplishments during your tenure?
I’m definitely pleased that we did not lose significant health care coverage during attempts to defeat or diminish the ACA. By the way, the AAMC wasn’t necessarily defending the ACA — we were defending coverage. If Republicans had developed a policy that was better, we would have supported it.
I’m also glad that the federal payments that our members receive have been protected. Teaching hospitals often treat very complex patients as well as many uninsured patients, and they train future providers. It takes a lot of resources to do that, and it’s essential that the federal government offset some of those costs.
I’m proud that after decades, we broke through the freeze on Medicare-funded [medical] residency slots. In December 2021, Congress approved an additional 1,000 Medicare-funded residency slots that will go to train physicians in underfunded and under-resourced areas. These were the first new residency slots approved since 1997.
I’m proud of our work on immigration issues and health equity, recognizing that there is much more to do, and of our current work to emphasize the importance of mental health issues in this country and our efforts to support physician well-being.
I’m proud that we were able to learn from our members how much they’ve been doing during COVID-19 and that we let policymakers know about that work and what our members needed to support it.
Looking ahead five or 10 years, what do you consider key policy concerns?
The first thing is that the Medicare program is expected to go insolvent in 2026. That means that there will not be enough money to pay Medicare’s bills. We need to look at how to constrain spending growth while continuing to ensure high-quality care. I worry about how we will do that. Do we need to look at alternative payment models, for example?
I also think we need to focus on protecting research funding. There’s been a lot of attention placed on science during COVID-19. It’s crucial that we educate the public and policymakers about the importance of science. We in academic medicine spend so much time doing this important work that we sometimes fail to remind people about the value of doing it.
As you prepare to leave, can you share what you consider some of the heartbreaks and joys of your work?
Well, part of my job is to be worried all the time. The job is stressful because issues emerge suddenly and change quickly, and we often don’t have control over the outcomes of our efforts. But this also makes the job challenging and exciting and fun to get up and do every day. And I am surrounded by talented colleagues both in the AAMC’s Office of Government Relations and the rest of the association, and that makes my job a lot easier.
I must say that it has been an absolute honor to work on behalf of academic medicine and its patients.
I truly believe teaching hospitals and medical schools are the backbone of the American health care system. I appreciate that they treat everyone who comes through the door, and I respect the passion of people who work in academic medical centers. In fact, I always say that our best advocacy is the work that academic medical centers and their staff do every single day.