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Tuesday Jan 03, 2017

AAFP Urges Congress to Uphold Health Care Coverage Expansion

Happy New Year!  

I hope each of you had a nice and restful holiday and were able to spend time with family and friends. With the holidays behind us, it's time to turn our attention to Washington, D.C. and what will certainly be a busy first few months of legislative activity.

This week, the 115th Congress will convene and begin consideration of legislation that, if approved, would set in motion a series of events that could undermine the significant improvements that have been made in our health care system during the past decade. Specifically, in danger are the gains we have made in reducing the number of uninsured children and non-Medicare eligible adults, as well as a number of important insurance reforms that protect individuals in all insurance markets from discrimination based on age, race, gender, health condition, and socio-economic status.

The AAFP has long advocated for health care coverage for all Americans. Our policy, which dates back to 1989, clearly states that our goal is, "to provide health care coverage to everyone in the United States through a primary care based system built on the patient-centered medical home."

During the past two decades, the AAFP has worked in a bipartisan manner to identify and implement policies that have moved us closer to this laudable goal. The enactment of the Children's Health Insurance Program (CHIP) in 1997 provided health care coverage to millions of previously uninsured children. The Patient Protection and Affordable Care Act (ACA), enacted in 2010, built on the progress made through CHIP and extended access to affordable health care coverage for millions of previously uninsured, non-Medicare eligible adults and additional children not previously eligible for CHIP coverage. Throughout these reforms, we worked to solidify the important role of primary care and the value of a longitudinal relationship with a family physician. In 2015, our delivery system and payment reform efforts were captured, in part, through the bipartisan policies contained in the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA).

Each of these steps was a result of the AAFP's consistent pursuit of our policies and a never wavering commitment to patients and their family physicians. We still have work to do, but we should recognize that we have made substantial progress towards our goal of providing health care coverage to everyone.

According to Gallup, the number of uninsured is at a historic low of 11 percent. This is an incredible statistic when you consider that less than a decade ago, our uninsured rate was nearing 17 percent with nearly 50 million people uninsured. The greatest gains in health care coverage have occurred among our most vulnerable populations and young adults. The uninsured rate among those making less than $36,000 annually has declined from 30.7 percent to 20.4 percent. The uninsured rates for those between 18 and 25 years of age has decreased from 23.5 percent to 14.9 percent, and the uninsured rates for those between 26 and 34 years of age has decreased from 28.2 percent to 19.4 percent. 

These decreases in the number of uninsured are significant and reflect the consequential provisions enacted into law. These accomplishments are now under scrutiny, if not outright attack. Now is the time to accelerate our efforts on reducing the number of uninsured, not roll them back. 

The AAFP's policies and advocacy on these issues moving forward are guided by a standard that has been proven accurate and factual the world over: The two primary factors that are most indicative of better health and more efficient spending on health care are continuous health care coverage and a usual source of care, normally through a primary care physician.

In the weeks ahead we will be aggressively  defending and advancing our priorities with the House and Senate. There is not room in this space to outline each of the AAFP's policy priorities, but I do want to stress six key objectives:

  • Insured individuals should not become uninsured as a result of any legislative or administrative short-term actions or inactions. Individuals who have already secured health care coverage should retain that coverage, including those who obtained coverage as a result of their state's expansion of its Medicaid program. Furthermore, individuals should be protected from loss of coverage that could result from inactions that result in a destabilizing of the individual and small-group market.
  • Premium assistance and cost-sharing reduction subsidies aimed at assisting qualifying individuals with the purchase of health care coverage and/or paying their deductibles and co-pays should be preserved.
  • There should be a viable and equitable safety net health care program for low-income individuals including those enrolled in Medicaid and CHIP. The basic benefits of the safety net should be universal, meaning beneficiaries are guaranteed health care coverage that is equitable to such coverage in any of the other states. We support continuation of incentives for additional states to expand Medicaid and those that have expanded to keep it.
  • Policies prohibiting health insurers from imposing annual and lifetime caps on benefits should be retained and made applicable to all insurers, public and private.
  • Insurance reforms that prevent discrimination against individuals in the insurance market must be preserved. Specifically, individuals should not be denied health care coverage, charged higher premiums, or have their coverage canceled based on a current or pre-existing health care condition, color, national origin, sex, age, disability, family history, race, gender, or income. We particularly call for continuation of protections that ensure that women are not charged higher premiums than men because of gender.
  • All health insurance products should be required to cover evidence-based essential benefits including coverage, at no out-of-pockets cost to insured persons, to those preventive care and vaccines identified by the U.S. Preventive Services Task Force and other designated evidence-based assessment entities.

Wonk Hard -- The Process
I am not 100 percent certain about the process, but here is how we think things will play out during the next few weeks or months.

  • This week, the Senate will consider a budget resolution for fiscal year 2017. The budget resolution will contain so-called "reconciliation instructions" that will request that the Finance and Health, Education, Labor, and Pensions (HELP) Committees identify a set amount of savings in their areas of jurisdiction (in this case, the ACA). The budget resolution requires 50 hours of debate in the Senate, so final passage would occur on or around Jan. 6.
  • Upon approval by the Senate, the House will consider the Senate-approved budget resolution. The House version of the legislation will be identical with the exception that it will instruct the Ways and Means, Energy and Commerce, and Education and Workforce Committees to identify savings in their areas of jurisdiction (again, in this case, the ACA).
  • Upon approval of the budget resolution by both chambers, the committees will begin drafting legislation aimed at repealing or reforming major portions of the ACA.
  • The product produced by the committees will then be assembled by the Budget Committee in the House and prepared for consideration by the full House. The legislation would impact revenues (taxes), so it must originate in the House.
  • Assuming the House approves the legislation, it would then be sent to the Senate for consideration. The legislation would be considered under reconciliation, so passage in the Senate only requires 51 votes. Republicans will hold 52 seats in the 115th Congress.
  • If the Senate approves the House-passed bill, the legislation would go to the president for enactment into law. If the Senate alters the House-passed bill, it must return to the House for passage prior to being sent to the president.
  • It is important to note that this is a long and complicated process. Getting a bill through five committees and two chambers will not be an easy task. Factor in the issue and the impact it will have on millions of people, and the level of complexity increases significantly.


Not sure what the Academy wunderkinds are thinking but here in rural America things are different. Folks who had good insurance had their companies drop insurance. Then they buy high deductible insurance which is too expensive to use. As an analogy, it's like being given a car w/o tires or gas neither of which you can afford. . Yes you have a car but it's pretty useless to you. Oh and the expanded Medicaid? For dual enrollment with Medicare, have you noticed that Medicaid pays nothing? That's right sports fans they don't pay the deductible and copay. And since the patient is awarded Medicaid they can't be changed for those. So the physican is collecting at least 25% less than Medicare. When the hell was I asked to vote on this "tax". Effective 1 April we are voting with our feet --- no Medicaid.

Posted by Mike Schaub MD on January 03, 2017 at 11:37 AM CST #

Thank you for continuing to focus on protecting patients. These are all obvious issues for the AAFP to care about but I know that some will say that we have no place in politics. As a family physician, I can't help but care
--that my patients ALL have access to medical care, including both primary and specialty care and all the recommended preventative care. I remember when being insured didn't mean much--patients still couldn't get colonoscopies or have their pregnancy covered!
--that my patients with pre-existing conditions are able to get the same insurance and medical care as my patients without (and this is important for me too! As a solo physician with a history of VAD and CVAs, I am uninsurable if we lose that protection)
--that my patients with severe chronic conditions, especially children with significant special needs or childhood cancers or genetic conditions, will not simply die or suffer because they've reached their lifetime limit

To me, this is not only an important part of being a physician, it's just plain human decency. That a country as rich as ours would refuse to provide basic medical care to every citizen is horrifying. Thanks for fighting the good fight!

Posted by Robin Dickinson on January 03, 2017 at 11:38 AM CST #

I applaud the Academy's efforts. I think that an additional Academy priority should be the preservation of Medicare.There seems to be some congressional desire to "privatize" the system, perhaps by creating a voucher program. This will very likely reduce access to the full array of services offered currently and increase out-of-pocket costs to beneficiaries. Health care cost inflation is at a historically low level, due at least in part to ACA reforms, many of which should be preserved under any future "repeal and replace" programs.

Posted by Jacob Lazarovic MD on January 03, 2017 at 12:17 PM CST #

FYI, Medicare was never meant to be a healthcare system, it was meant to be a tax. Which explains why there is no money!!!! It was already spent on pork by our politicians. And Obamacare only got thru SCOTUS because it was considered a tax. Just for interest, you might want to look up the salaries of the executives of your local Medicaids. For Molina (here in Michigan) the CEO got $10M in 2015 (and he is a doc). We need to get away from the idea that we are here to save the world. Don Quixote lost in his battle against windmills. When asked by our current Medicaid patients "what can they do", I respond contact your reps in DC. Do I care? Absolutely. Do I care that CMMS and insurance companies are making it more difficult to see patients, b/c we are spending more time collecting data for them? Absolutely. Do I care that physicians are down to only 27% of their time face-to-face seeing patients b/c they are playing w/ EMR and entering said data? Absolutely. My answer: Less is more. EMRs are a total waste. We should not be trying to further fix EMRs, we should be throwing them out! They are a digital solution to an analog problem. And government needs to be out of the health care system. It should be organized around local churches and non-profits. Then physicians and insurers and patients would all be geographically and financially in the same boat (and hopefully not on the federal USS Titanic).

Posted by Mike Schaub MD on January 03, 2017 at 01:10 PM CST #

I also have not seen "Obamacare" be a good thing for most of my patients or my practice. Many of my patients went form decent, low copay and low deductible plans to terrible high copay and high deductible plans. This has terribly hurt my bottom line. I am not sure if the Academy wants terrible coverage for everyone, perhaps MA for everyone who does not have Medicare or a good plan, which may end up being taxed as a "Cadillac" plan. I wonder where you practice if the totally misnamed Affordable Care Act has been good for a majority of your patients or your practice, but this has not been the case where I am in Northeast PA, unless perhaps you work in an underserved clinic. If it were not for the need to remain certified and get CME, I increasingly feel that the AAFP is drifting toward being as out of touch with real life practice as the AMA, and I would strongly consider giving up my membership.

Posted by Joseph A. Anistranski MD on January 03, 2017 at 02:23 PM CST #

Like other physicians who have commented, I've had more patients lose insurance benefits than gain them. Another handful initially get the ACA plans, but then cannot pay the premium and lose it within a couple of months due to nonpayment. I don't think the statistics quoted accurately reflect the truth.

Posted by Margaret Carter on January 03, 2017 at 03:44 PM CST #

I was NOT and still am NOT for the "Affordable Care Act." Sure, there are parts that are beneficial. You tout how many millions now have coverage. Do you have your stat on how many HAD insurance but now don't?? I, for one, have gone from $250/month for me and my wife to $1321/month for 2017. I think it is great and noble for the AAFP to want to include everyone in health insurance coverage. But at what cost?? We are bankrupt as a nation, and as currently configured, the ACA is bankrupting individuals and/or they are dropping their coverage. The AMA sold us out several years ago. I do not want the AAFP to sell us out either. How about looking at the BIG picture?? Hopefully, now that adults will be in charge in Washington, a reasonable and affordable solution can be achieved.

Posted by John Raines on January 03, 2017 at 04:12 PM CST #

Perhaps it is different in urban areas but ACA has been a disaster for my patients. More patients lost insurance than gained it and those that ended up transferring to ACA policies because they could not keep their old policies ended up with much higher premiums and deductibles. From the office perspective the tightening of the formularies and prior authorizations for outpatient testing has become a nightmare.

Locally most of the small independent practices (including mine) had to end up joining larger groups. One bright side locally is that the uninsured increased enough that one local physician dropped all insurance (private and government). She cut her overhead by more than 2/3 by not dealing with insurance and is more affordable for the uninsured although I still have more uninsured that I care for than before ACA.

With almost all of the insurance companies leaving the area under ACA things will be a challenge but if repealed then there will at least be hope that things could improve.

I am frustrated that the AAFP worked to create this monster and now appears to be working to keep things in a tailspin. With future legislative initiatives I wish that the AAFP would poll the membership and I think that at least 90% should approve of an action before the organization formally backs it. That may be a high standard but realistically if one is going to say that we support something as an organization then there should be overwhelming support for it within the organization. I at least hope that the salaries and overhead for the "advocacy" branch of the AAFP do not come from general dues.

Posted by Brian Billings MD on January 03, 2017 at 04:34 PM CST #

Glad to see that others out there have seen the sometimes devastating effects of the current health insurance situation. Health insurance doesn't equal access to care! So many people aren't able to access services when they need them because they can't afford an opffice visit in addition to the high premiums because of high deductibles. It's frustrating for them to turn around and see terrible abuse of the health care system by many who have no responsibility for their health care costs. So much for being fair and equitable. The AAFP statement above included the following, "Now is the time to accelerate our efforts on reducing the number of uninsured, not roll them back." Since when did we become the front lines for enrolling people for health insurance? Our patients need to be our first priority and signing up everyone for a policy that doesn't help them get good care is not the way to do it! I, also, am concerned that the AAFP pushes forward with positional statements and efforts that were never endorsed by the membership. I made sure to inform my representatives in Congress that my views differ from the AAFP. Paying for insurance policies without addressing more significant barriers in access to health care is not where we should be focusing our efforts.

Posted by Orie Browne on January 03, 2017 at 05:37 PM CST #

Access to my office costs far less than insurance. Most of my uninsured patients before the ACA paid me 90 dollars and then paid for their meds. Now they pay 200-600 dollars a month for insurance and still pay for their deductible. They aren't happy and neither am I. Family docs as a group are in favor of doing things that improve healthcare. Our AAFP seems to have lost the distinction between having insurance and having healthcare. Yes you need insurance for a catastrophic illness.. You don't need insurance to come see me. No progress can be made until we all can define "what is access to healthcare".

Posted by Bruce Russell MD on January 03, 2017 at 06:21 PM CST #

So the AAFP asked me to send a form letter to my legislators to tell them "Keep Your Patients Covered. Tell Them What You Think." WHAT? AAFP has already typed out "What I Think?" Jeeze, make this STOP. AAFP you do NOT represent us. You are not a representative body for the us grunts. I disagree with what the AAFP thinks I should think. This is spinning more and more out of control

Posted by Karl N. Hanson, MD on January 03, 2017 at 10:19 PM CST #

I agree with Dr. Hanson. I'm tried of The AAFP telling me what to think. Before you send AAFP lobbyist to DC to tell them what "WE" think, why don't send out a survey to accurately determine the membership's opinion? I had more patients lose their insurance than gain coverage. Those that picked up the ACA insurance found their policy more expensive and with less benefits. I believe health care in this country needs fixed, but the ACA is not the answer. As a member of a group who has embraced The ACA I now spend much more time documenting required information than caring for my patients. Get the facts before you tell congress "WHAT I THINK".

Posted by RICHARD R. BURDEAUX SR, DO on January 04, 2017 at 05:20 AM CST #

Why is there no effort on the part of our leadership to find out what its members think? The disconnect between the AAFP leaders and many of its members is enormous as indicated by many of the above comments. Unless you can afford to take time off and go to the annual meeting, you have no voice. I would be interested in knowing what percent of our members remain in the AAFP (like myself) only for the CME benefits.

Posted by KEITH DINKLAGE on January 04, 2017 at 07:57 AM CST #

That Mr. Martin and the AAFP are still patting themselves on the back for helping to pass the profoundly anti-physician MACRA is a good indication of just how far off the rails this organization has gone.

Posted by D Claude on January 04, 2017 at 09:19 AM CST #

Very sad that the AAFP is still promoting Obamacare after all of the negative feedback from Academy members. Maybe its time to start looking for an AAFP alternative.

Posted by David Lieb, solo in Indiana on January 04, 2017 at 01:28 PM CST #

According to HHS data at least 20 million more Americans have health insurance since the ACA passed in 2010. As a Family Physician who cares for patients from a wide economic spectrum, I know IT IS BETTER TO HAVE HEALTH INSURANCE FOR YOURSELF AND YOUR FAMILY THAN NOT HAVE IT period. As the only major industrialized nation without some form of universal health care we are left to build a patch work of healthcare plans and the ACA with its faults is an essential part of that. The last thing these millions of Americans need is to repeal the ACA. It is time to move forward not to "repeal and replace" but to repair and expand. I certainly applaud the AAFP for its past, present and future advocacy efforts to ensure better access, better care and better health for all Americans.

Posted by Michael Baxter MD on January 04, 2017 at 09:24 PM CST #

I agree with those who are commenting that the AAFP needs to survey members. The activities of the AAFP are not considering opinions and experiences of the membership especially for those of us actually practicing medicine in various communities. When I read academy postings, I don't believe that the writers have any real world knowledge of the current effects of legislation on those of us "in the trenches". Like most of the political arena these days, it seems that those persons actually participating in "representing" us are just advocating for a political position to suite their own idealisms. Please start surveying us about what the effects of legislation and insurer actions have on our practices and ask us what are patients are saying.

Posted by T Shields, M.D. on January 05, 2017 at 09:59 PM CST #

I agree the ACA is flawed, like the doctor commented about being given a car without tires and gas .However it is an attempt and I cannot imagine the Republicans coming up with something better while trying to defund the system .I agree with what the leadership is trying to do, but hope the realty strikes that we would do better with a single payer system like the rest of the wealthy nations of the world . We compare very poorly with other countries and pay more.As long as we are beholden to the health care industry and Big Pharma we will continue to do poorly.

Posted by tim hoffmann m.d on January 10, 2017 at 07:27 PM CST #

Thank you, AAFP, for helping to advocate for the ACA and pushing back against regressive policies. A single payer system would be ideal and someday we may get there (after everything else fails, it seems...) The ACA is an enormous gift to the insurance industry, but it's far better to have coverage and patient protections than not. If it's partisan to increase access to health care coverage, then you need to take a hard look at your definition of partisan.

And if you don't like the AAFP's lobbying efforts, then get involved in your state or local chapter, special constituency, member interest group, and be a part of the decision making. No one is stopping you!

Posted by Alap Shah on January 17, 2017 at 11:25 AM CST #

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About the Author

Shawn Martin, AAFP Senior Vice President of Advocacy, Practice Advancement and Policy.

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The opinions and views expressed here are those of the authors and do not necessarily represent or reflect the opinions and views of the American Academy of Family Physicians. This blog is not intended to provide medical, financial, or legal advice. All comments are moderated and will be removed if they violate our Terms of Use.