2021 Policy Priorities to Improve the Nation’s Health
The year 2020 has presented immense challenges for our communities, our patients, and our nation — from a global pandemic to a national reckoning with structural racism to economic uncertainty — underscoring the critical need for the federal government and all of us to work together toward a path forward. The Association of American Medical Colleges (AAMC) is eager to work with our nation’s leaders to advance policy priorities that will strengthen the nation’s health and well-being.
Together, our medical schools, teaching hospitals, faculty physicians, and scientists fulfill their four missions of providing health care, medical education, medical research, and community collaborations, with each area promoting and supporting the others. Through policies that affect health care delivery, research, education, health equity, and more, the federal government is a key partner in sustaining the vitality of the nation’s academic medicine ecosystem, which is essential to improving the health of all.
As major centers of research, AAMC member institutions discover and pioneer new and more effective medical diagnostics, prevention strategies, therapeutics, and cures. With leading medical experts, the most advanced technologies, and the latest evidence-based treatments, these centers of medical excellence also work to develop more effective models of health care delivery that improve the quality of patient care and lower costs. Our members also work toward a healthier future for all by building partnerships and cultivating trust as anchor institutions in their communities.
As described more fully below, AAMC members are key to ensuring high-quality health care for all patients, including the vulnerable and most complex, while also helping improve the well-being of their communities. At the same time, these institutions are vital economic engines at the local, state, and national levels. They generate jobs, pay wages, and support business and community development opportunities. In 2017, AAMC-member institutions added more than $562 billion in value to the nation’s economy, which represented about 3% of the U.S. GDP. They were also responsible for generating 6.3 million jobs in communities nationwide.
Leveraging AAMC Expertise
About the AAMC
The AAMC (Association of American Medical Colleges) leads and serves the academic medicine community to improve the health of people everywhere. The association is uniquely poised to help develop a more equitable health care system and healthier future by drawing on the expertise of the AAMC, as well as our 155 U.S. medical schools, more than 400 teaching hospitals and health systems, including U.S. Department of Veterans Affairs medical centers, and more than 70 academic societies.
Collectively referred to as “academic medicine,” AAMC-member institutions and physician faculty work together to educate and train the next generation of physicians, biomedical scientists, and other health professionals. During the COVID-19 pandemic, academic medicine has been defining the front lines, serving patients and communities across our nation, identifying new protocols for care, and conducting research for treatments and vaccines.
Our institutions and their leaders, physicians, scientists, health care teams, learners, educators, and staff have been and will continue to be essential partners with their communities. Building on our internal expertise and the experiences of our member institutions, the AAMC developed and released a road map in July 2020, along with subsequent guidance, that recommends a new way forward for the nation on COVID-19.
Ensuring High-Quality Care for Patients
AAMC-member teaching hospitals and faculty physicians cultivate and provide high-quality health care, especially for the most complex and vulnerable patients, many of whom are unable to receive care elsewhere. While only 5% of all inpatient, short-term, nonfederal U.S. hospitals are AAMC-member teaching hospitals, these teaching hospitals and their physicians provide a disproportionate amount of care for their communities, including:
- 25% of all days spent in hospital inpatient care.
- 22% of all days Medicare patients spent in inpatient care.
- 27% of all days Medicaid patients spent in inpatient care.
- 34% of all charity care costs.
AAMC-member teaching hospitals also provide specialized services to their communities that often are unavailable elsewhere, including:
- 94% of lung transplants.
- 71% of kidney transplants.
- 61% of pediatric intensive care beds.
- 69% of all Level 1 trauma centers.
The Medicare program provides coverage for over 62 million individuals, and it also helps support the vital and unique missions and complex patient populations served by teaching hospitals and their physician faculty. This support helps teaching hospitals train new physicians to meet the increasing requirements of an aging population and partially offsets additional patient care costs incurred by teaching hospitals for the unique services they provide and the more complex patient populations they treat.
While remaining financially stable, Medicare must continue to evolve in how it provides patient care, ranging from telehealth and in-home services to population health payment models. Reevaluating the Stark anti-kickback laws are key to this transformation. Medicare must also continue its special mission payments to teaching hospitals and other urban and rural safety-net providers to ensure beneficiaries have access to high-quality care and the nation continues to have a high-quality, robust workforce and delivery system.
Medicaid is the largest health insurance program in the country. It covers one in five Americans, including many with complex and costly health care needs and many in nursing homes. It is a key source of coverage for the poorest and most vulnerable patients. Major teaching hospitals and their faculty physicians provide care for a disproportionate number of these patients, despite unsustainably low Medicaid reimbursements.
The Medicaid Disproportionate Share Hospital program (DSH) provides vital funding to safety-net hospitals, including many teaching hospitals, that provide care to a high proportion of Medicaid beneficiaries and uninsured patients. Congressional and executive branch support of both the Medicaid program, Medicaid DSH, and other supplemental payments is crucial not only to supporting the safety-net providers who care for this important population but also to being part of the solution in addressing and narrowing the gap in health inequities that for too long has gone without sufficient attention.
Other Health Care Coverage
Since the enactment of the Affordable Care Act, the number of uninsured nonelderly Americans has decreased from over 46.5 million in 2010 to just below 27 million in 2016. However, that number has steadily increased since 2017, and in 2019, nearly 30 million Americans lacked health care coverage at some point. These numbers are expected to rise even more in 2020 due in large part to higher unemployment rates during the COVID-19 pandemic. For the health of all, it is essential the nation finds ways to increase access to affordable health coverage, including sustaining and strengthening programs that provide access to health care coverage and narrow the gap in health care felt by many communities. Without coverage, individuals often forgo routine care, which leads to more costly and complex care later.
340B Drug Pricing Program
At no cost to the federal government, safety-net hospitals, many of which are teaching hospitals, and other provider types that are eligible to participate in the 340B Drug Pricing Program leverage discounts from pharmaceutical companies to provide access to programs and services for their communities, including low-income, rural, and other underserved patients. These hospitals use their savings from the 340B program in a variety of ways, including programs to provide free or substantially discounted prescription drugs to low-income patients, improve access to specialized care previously unavailable in some areas, establish and invest in neighborhood clinics, and more. Congress and the executive branch must continue to support this program and ensure vital services remain accessible to vulnerable patients and communities.
Driving New Discoveries
Scientists and physicians at medical schools and teaching hospitals pioneer discoveries and innovations, bringing them from the laboratory bench to the patient bedside. The advances that come from this research, much of which is supported in part by federal agencies, lead to new cures, preventive interventions, diagnostics, and treatments for disease that improve the lives of millions of patients.
As the leading voice and advocate for America’s medical schools and teaching hospitals, the AAMC works to prepare a diverse medical research workforce and champions an environment in which medical discovery can flourish. From foundational science to clinical applications, a strong commitment to discovery benefits people everywhere, and federal policies that promote a thriving national research agenda are key to this goal.
NIH Funding and Policies
Research supported by the NIH, funded primarily through the annual federal appropriations bill for the U.S. Department of Health and Human Services (HHS), is the foundation of scientific knowledge and drives medical innovation that improves health. Over half of the life-saving research supported by the NIH takes place at medical schools and teaching hospitals, where scientists, clinicians, fellows, residents, medical and graduate students, and postdoctoral researchers work side by side to improve health and save lives through research. Ensuring the continuation of advancements in medical research requires sustaining robust, predictable increases in the NIH budget over the long term.
The unique partnership between the NIH and the nation’s medical schools and teaching hospitals, forged just after World War II, deepens our understanding of the mechanisms of human health and disease and lays the foundation for improved health and quality of life. With critical support for the NIH, researchers at AAMC-member institutions will continue to develop innovative research methods, forge interdisciplinary collaborations, promote effective data-sharing, and address inequities to improve the lives of patients across the country and the world. Through all these activities, the federal commitment to research conducted at academic medical centers not only improves health but also strengthens local and regional economies and the nation’s global competitiveness.
Other Health and Research Agencies
Medical discovery and advancement requires effective research across a continuum from basic science to clinical, health services, and health systems research. Accordingly, other federal agencies, both within and outside HHS, also support vital work at medical schools and teaching hospitals to advance the continuum of research and discovery. These agencies include the National Science Foundation (NSF), the U.S. Department of Veterans Affairs (VA), and the Agency for Healthcare Research and Quality (AHRQ), as well as nongovernment organizations, such as the independent Patient-Centered Outcomes Research Institute (PCORI). A strong federal investment is critical to support the full spectrum of science and science agencies.
Research Training and Workforce
In addition to teaching the nation’s physicians, academic medical centers train the majority of biomedical scientists in the United States. The ability to maintain a productive, innovative, diverse, and multidisciplinary scientific and medical research workforce depends on the success of academic institutions in training, recruiting, and retaining talented and dedicated scientists, both nationally and internationally, and in researchers obtaining independent, permanent positions. Our future progress in research is dependent on sufficient funding and opportunities to ensure research careers are an attractive and viable option for new generations of physicians and biomedical scientists.
Training Tomorrow's Health Care Workforce
AAMC-member medical schools and teaching hospitals play a crucial role in preparing future physicians who help create a healthier future for all. With the AAMC projecting a physician shortage between 54,100 and 139,000 physicians by 2033, programs that invest in training future doctors are more crucial now than ever before. Additionally, if health care access were equitable across race, health insurance coverage, and geographic location, the United States would require almost 150,000 more physicians as of today. Federal programs administered through Medicare, the Health Resources and Services Administration (HRSA), the U.S. Department of Education, the VA, and the U.S. Department of Defense (DoD) are fundamental for training a robust and diverse health care workforce that is ready to serve our nation’s most vulnerable patients and address any public health emergency.
Graduate Medical Education
GME — clinical training at teaching hospitals for our future physicians after medical school — is crucial in addressing America’s current and future physician shortage. Unfortunately, Medicare-supported training positions have been effectively frozen since 1997. Increasing federal investment in GME is the first step in producing more physicians to care for our nation’s patients. Additionally, Children’s Hospital GME and Teaching Health Centers GME, administered by HRSA, as well as GME programs administered by the VA and DoD, provide vital support for training physicians in primary care and a multitude of subspecialties.
HRSA Health Workforce Programs
The HRSA Title VII workforce development programs are crucial in training a diverse and culturally competent health workforce to treat our nation’s most vulnerable patients. The Title VII programs, funded through annual federal appropriations for the Department of Health and Human Services, invest in scholarship, loan repayment, and mentorship programs for future health care professionals from underrepresented minority, rural, and disadvantaged backgrounds. The HRSA programs also support interprofessional training in community-based settings to help shape the nation’s health workforce across primary care, public health, geriatric, and mental health disciplines.
Student Aid and Public Service
While medical school remains an excellent personal financial investment, federal student loans administered by the Department of Education — such as Direct Unsubsidized and GradPLUS loans that cover the full cost of attendance — help students from disadvantaged backgrounds access financing. Federal recruitment programs, such as Public Service Loan Forgiveness, the National Health Service Corps, and those administered by the VA, DoD, and HHS’ Indian Health Service, encourage graduates to pursue careers that benefit communities in need by providing student loan relief to physicians who serve in Health Professional Shortage Areas and nonprofit or government facilities. Federal financial and policy support for these programs ultimately help improve the health of individuals and communities.
Immigration and Citizenship
A balanced approach to immigration and citizenship policy that attracts and retains the best and brightest from around the world is necessary for our nation’s health security. The U.S. health workforce and the patients it serves rely on health professionals from other countries, including many through the Deferred Action for Childhood Arrivals (DACA) program. These providers add diversity of culture and experience to our nation’s workforce. Their importance is amplified each year, as the nation faces growing physician workforce shortages that have been felt acutely during the COVID-19 national emergency.
Teaching hospitals and medical schools require a stable immigration system to attract talented students, trainees, and staff for vital education, research, and clinical programs. To ensure that undocumented members of the health care workforce are able to continue their employment, education, training, and research in the United States, the administration must retain DACA while Congress enacts legislation that would provide a permanent pathway to citizenship for these individuals. To avoid training disruptions and strained patient coverage, predictable and transparent immigration processes are important for timely onboarding of new medical residents each year on J-1 and H-1B visas. Well-considered immigration policies, such as the Conrad 30 J-1 visa wavier program, also help rural and other underserved communities recruit physicians. Congress should make permanent and expand the Conrad 30 program to help vulnerable patients affected by nationwide physician workforce shortages.
Investing in Healthier Communities
Academic medical centers serve at the crossroads of community health, health equity, and population health and are actively working to prevent and address persistent public health challenges, such as gun violence, maternal mortality, substance use disorders, and mental health concerns.
Throughout our history, structural racism and inherent biases have created health inequities that impact minority communities and other marginalized groups, who have borne the greatest burden of health insecurity. The COVID-19 pandemic has laid bare these existing health inequities, taking a disproportionate toll on marginalized people and communities throughout the nation. Medical schools, teaching physicians, and teaching hospitals play a unique role in fostering and participating in collaborations with community organizations, federal agencies, and other entities to address these challenges—in both times of crisis and on an ongoing basis—to promote health for people everywhere and reduce the inequities that exist between communities nationwide.
Health and Health Care Equity
Medical schools and teaching hospitals continuously work across all of their missions by collaborating with communities to ensure all people have the same opportunities to reach their full health potential—a state of health equity. As pioneers in research and clinical best practices, these institutions create the evidence base that makes the case for policies, partnerships, and practices that facilitate health equity. Diversity and implicit bias training for learners, researchers, and providers; social risk adjustment in screening, referral, and payment; and initiatives to increase diversity in clinical trials can all help improve health outcomes for underrepresented communities. As anchor institutions, academic medical centers also collaborate on interventions and research with federal, local, and community partners to address social factors, such as affordable housing, transportation, access to healthy food, job security, economic inequities, and environmental health.
Addressing Racism in Medicine
Historically, racism has affected every aspect of our collective national life, from education and opportunity to personal safety and community stability. Its impact on health is seen across the country, in large cities and small rural towns. In medicine, racism and racial bias contribute to health care inequities and public health crises, such as Black maternal mortality and the disproportionate impact of COVID-19 on minority communities. Academic medicine’s physicians, educators, hospital leaders, faculty, researchers, learners, and staff must lead by example, take bold action in partnership to help address racism and explicit and implicit bias in medicine, and mitigate racial inequities.
Teaching hospitals and their faculty physicians and staffs are critical to the U.S. health care system’s ability to respond to natural and human-induced disasters and other emergencies. As they have demonstrated during the COVID-19 pandemic, academic medical centers have decades of experience in mobilizing resources during times of crisis and often lead regional responses in collaboration with their state and local health departments, regional emergency management systems, and community partners. Maintaining emergency preparedness and mounting a robust response require a strong commitment to programs under the Centers for Disease Control and Prevention (CDC) and the Assistant Secretary for Preparedness and Response. The most effective preparedness strategy also requires ongoing, stable financial support for the nation’s core public health and health care infrastructures, including academic medical centers.
To operate most optimally, the nation’s health care system–including teaching hospitals and their affiliated medical school faculty–requires a strong public health infrastructure. Decades of underfunding at the national, state, and local levels, however, have strained foundational public health capabilities, as looming and ongoing threats—such as the COVID-19 pandemic—far outpace available resources. Robust, sustained investment in the CDC, HRSA, and other public health agencies is necessary to advance a national health security strategy and promote healthy communities.
Diagnosing our National Disease
David J. Skorton, MD, AAMC president and CEO, talks with Lonnie G. Bunch III, secretary of the Smithsonian Institution, about racism in academic medicine.
The Way Forward on COVID-19
A comprehensive, coordinated plan based on AAMC experts’ understanding of the pandemic as doctors, scientists, and medical educators.