Internists Say Affordable Care Act Enhancement Act Would Improve Access to Health Care

WASHINGTON, June 30 -- The American College of Physicians issued the following news release:

In a letter sent to leaders of the House of Representatives Energy and Commerce, Ways and Means, and Education and Labor Committees today, the American College of Physicians (ACP) applauded the committees' efforts to put forward legislation to improve upon the policies in the Affordable Care Act (ACA).

"ACP has long endorsed policies to achieve universal health insurance coverage and supported passage of the ACA in 2010. The ACA literally transformed the U.S. health care system by extending access to coverage, providing consumer protections and essential benefits, and improving quality of care for millions of Americans," wrote Jacqueline W. Fincher, MD, MACP, president, ACP. "Now more than ever, as this nation struggles through the COVID-19 pandemic, Americans need access to affordable care and coverage with all the current-law safeguards and protections in place so families do not fall into financial ruin due to a catastrophic illness, such as the coronavirus."

The Patient Protection and Affordable Care Enhancement Act (H.R. 1425) was passed by the House of Representatives on Monday afternoon. The legislation is designed to strengthen and expand on the policies in the ACA.

"Despite impressive improvements in insurance status, access to care, and economic security measures, the ACA is still not a perfect law, nor can it be, and several repeal efforts combined with poor stewardship threaten to exacerbate the law's problems," Dr. Fincher continued in the letter. "ACP believes the ACA needs to be further strengthened and, in May 2019, ACP released a new position paper entitled, "Improving the Patient Protection and Affordable Care Act's Insurance Coverage Provisions," as published in the Annals of Internal Medicine. ACP's paper calls for efforts to bolster the ACA, including stabilizing the health insurance market, expanding Medicaid, increasing competition in the marketplace, and amplifying awareness about how the ACA works to help patients and how to enroll in coverage plans."

In the letter, ACP went on to detail its support for policies in the legislation, including:

* Establishing a health insurance affordability fund to help reduce out-of-pocket costs for individuals enrolled in qualified health plans.

* Rescinding the short-term limited duration insurance regulation, since those plans are not required to comply with any of the ACA's consumer protections.

* Incentivizing Medicaid expansion by increasing matching federal funds provided to states who choose to expand their Medicaid programs after 2014.

* Providing Medicaid pay parity for primary care services so that clinicians are paid no less than Medicare rates.

* Permanently reauthorizing the Children's Health Insurance Program (CHIP). Since its inception in 1997, CHIP, together with Medicaid, has helped to reduce the number of uninsured children by a remarkable 68 percent.

* Establishing a fair drug pricing program to require the Secretary of Health and Human Services to negotiate with drug manufacturers to set a maximum fair price for certain drugs.

"ACP is glad to see the House of Representatives is putting forth this effort to improve the ACA and improve access to health care for the American people," said Dr. Fincher. "With the health crisis our country is facing due to COVID-19 we should all be working toward strengthening our health care system and not supporting efforts that would tear it down. Now more than ever we need to reject efforts that would prevent people from accessing health care services."

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To: The Honorable Frank Pallone, Chair, Energy and Commerce Committee, U.S. House of Representatives, Washington, DC 20515

The Honorable Robert "Bobby" Scott, Chair, Education and Labor Committee, U.S. House of, Representatives, Washington, DC 20515

The Honorable Richard Neal, Chair, Ways and Means Committee, U.S. House of Representatives, Washington, DC 20515

Dear Mr. Chairmen,

On behalf of the American College of Physicians (ACP), I am writing to applaud your efforts in introducing legislation designed to enhance the Patient Protection and Affordable Care Act (ACA), the 2010 landmark law that instituted transformational changes to the U.S. health care system. The Patient Protection and Affordable Care Enhancement Act (H.R. 1425) is designed to make improvements to existing law by expanding access to health care coverage and services, strengthening protections for people with pre-existing conditions, making prescription drugs more affordable, and reversing harmful regulations meant to undermine the law. ACP supports many of the policies outlined in H.R. 1425, as discussed in detail below, and reaffirms its position that the ACA should not be repealed.

The American College of Physicians is the largest medical specialty organization and the second-largest physician membership society in the United States. ACP members include 159,000 internal medicine physicians (internists), related subspecialists, and medical students. Internal medicine physicians are specialists who apply scientific knowledge and clinical expertise to the diagnosis, treatment, and compassionate care of adults across the spectrum from health to complex illness. Internal medicine specialists treat many of the patients at greatest risk from COVID-19, including the elderly and patients with pre-existing conditions like diabetes, heart disease and asthma.

REFLECTIONS ON THE PATIENT PROTECTION AND AFFORDABLE CARE ACT

ACP has long endorsed policies to achieve universal health insurance coverage and supported passage of the ACA in 2010. The ACA literally transformed the U.S. health care system by expanding access to coverage, providing consumer protections and essential benefits, and improving quality of care for millions of Americans. Now more than ever, as this nation struggles through the COVID-19 pandemic, Americans need access to affordable care and coverage with all the current-law safeguards and protections in place so families do not fall into financial ruin due to a catastrophic illness, such as the coronavirus.

Despite impressive improvements in insurance status, access to care, and economic security measures, the ACA is still not a perfect law, nor can it be, and several repeal efforts combined with poor stewardship threaten to exacerbate the law's problems. ACP believes the ACA needs to be further strengthened and, in May 2019, ACP released a new position paper entitled, "Improving the Patient Protection and Affordable Care Act's Insurance Coverage Provisions," as published in the Annals of Internal Medicine. ACP's paper calls for efforts to bolster the ACA, including stabilizing the health insurance market, expanding Medicaid, increasing competition in the marketplace, and amplifying awareness about how the ACA works to help patients and how to enroll in coverage plans. The paper identifies common-sense approaches to improve the ACA as internists continue to advocate for universal health care for all patients and consumers.

PROVISIONS SUPPORTED BY ACP IN H.R. 1425

Establishing a Health Insurance Affordability Fund

Sec. 106 of the bill allocates $10 billion annually to states so they can establish a state reinsurance program or use the funds to provide financial assistance to reduce out-of-pocket costs for individuals enrolled in qualified health plans. It also requires the Centers for Medicare and Medicaid Services (CMS) to establish and implement a reinsurance program in states that do not apply for federal funding.

ACP's Position: Many good things came out of the ACA, but it is also the case that the health insurance marketplace has been struggling over the past few years, due to a confluence of many factors. Premiums have been rising, and many health insurers have pulled out of the individual health exchanges. In addition, the administration and Republican-led efforts in Congress have taken or proposed actions that non-partisan researchers have found will further destabilize the market by increasing premiums, undermining patient protections, and resulting in "adverse selection" among persons obtaining coverage in the individual market. ACP policy states that the federal government should stabilize the marketplace by establishing a permanent reinsurance program. Reinsurance can help ensure that patients get to keep the coverage they have while protecting insurers from high costs.

Rescinding the Short-term Limited Duration Insurance Regulation

Sec. 107 of the bill reverses the administration's final rule expanding short-term, limited-duration health plans, which are not required to comply with any of the ACA's consumer protections (protections for pre-existing conditions, guaranteed issue, community rating, essential health benefits, and many others).

ACP's Position: ACP supports reversing this final rule precisely because these short-term plans would not be required to include all of the essential health benefits currently required of all plans sold in the individual insurance market and would allow insurers to charge more for plans needed by individuals with pre-existing conditions. Such short-term plans typically do not cover prescription drugs, maternity care, mental health, and substance use disorder treatments, putting individuals and families that enroll in such plans at risk if they develop a condition requiring such services. Because these plans also may attract people who are healthier, people who remain in the ACA-qualified plans are likely to be sicker, resulting in double-digit premium increases for qualified health plans, more uninsured persons, and increased federal spending, according to independent researchers.

Incentivizing Medicaid Expansion

Sec. 201 of the bill provides 100 percent federal medical assistance percentage (FMAP) for Medicaid expansion beneficiaries for the first three years after a state expands Medicaid, and then scales down to 95 percent FMAP, 94 percent FMAP, and 93 percent FMAP, for, respectively, years four, five, and six. In year seven and beyond, the FMAP for the expansion population would be 90 percent. This enhanced FMAP schedule was available to states that expanded Medicaid beginning in 2014. The bill would provide parity to states that chose to expand Medicaid subsequent to 2014.

ACP's Position: ACP reaffirms its support for Medicaid expansion. All states should fully expand Medicaid eligibility and should not apply financially burdensome premiums or cost-sharing requirements, lock-out periods, benefit cuts, or mandatory work or community engagement policies that have the effect of reducing enrollment among vulnerable individuals. ACP has long-supported the Medicaid program as vital in the effort to ensure that this nation's most vulnerable population has access to health coverage. ACP's advocacy has focused on protecting the Medicaid program, encouraging states to expand their programs, and opposing efforts by federal lawmakers to cut/cap the program, or otherwise imposing mandatory work requirements, premiums and cost-sharing for vulnerable individuals, and benefit cuts.

Providing Medicaid Pay Parity for Primary Care Services

Sec. 206 of the bill reinstates and reauthorizes, for four years, through Sept. 30, 2024, the ACA's increased payments for primary care physicians who treat Medicaid beneficiaries to require that they are paid no less than the Medicare pay rate. Eligible entities include, among others, physicians with a primary specialty designation of family medicine, general internal medicine, pediatric medicine, or obstetrics and gynecology but only if the physician self-attests that the physician is Board certified in family medicine, general internal medicine, pediatric medicine; or obstetrics and gynecology.

ACP's Position: ACP has long-standing policy supporting reinstating Medicaid pay parity for primary care services. As noted in a recent joint letter to Congress on behalf of ACP, the American Academy of Family Physicians, the American Academy of Pediatrics, and others, Medicaid payments for services are significantly lower than Medicare payments for the same services. On average, a clinician treating a Medicaid enrollee is paid about two-thirds of what Medicare pays for the same services and only half of what is paid by private insurance plans. Primary care clinicians commit themselves to a long-term relationship with all their patients -- including Medicaid beneficiaries -- and provide not only first-contact and preventive services, but also the long-term care for chronic conditions that minimizes hospital admissions and reduces costs to the system. Increasingly inadequate Medicaid payments impede the ability of clinicians and other "providers" to accept more Medicaid patients, particularly among small practices, and threatens the viability of practices serving areas with a higher proportion of Medicaid coverage.

Permanently Reauthorizing the Children's' Health Insurance Program (CHIP)

Sec. 207 of the bill permanently authorizes sufficient funding for CHIP, as it is currently set to expire at the end of fiscal year 2027.

ACP's Position: ACP has been a staunch supporter of CHIP over the years and has advocated for a long-term extension of funding for the program. Since its inception in 1997, CHIP, together with Medicaid, has helped to reduce the number of uninsured children by a remarkable 68 percent. CHIP has a proven track record of

providing high-quality, cost-effective coverage for low-income children and pregnant women in working families.

Establishing a Fair Drug Pricing Program

Sec. 301 of the bill requires the Secretary of Health and Human Services (HHS) to establish a Fair Price Negotiation Program to negotiate with drug manufacturers in order to obtain a maximum fair price (MFP) for certain selected drugs. When establishing this program, the Secretary must publish a list of 250 negotiation-eligible drugs, which encompass the 125 covered part D drugs with the greatest net spending, as well as 125 other drugs that represent the greatest net spending in the United States and the U.S. Territories that are branded, single-source drugs that lack generic or biosimilar competition. From this list, the Secretary shall select no fewer than 25 drugs to negotiate in each of the first year of the program, which increases to no fewer than 50 drugs each year beginning in 2024. In addition to the minimum number of selected drugs the Secretary is required to negotiate, the Secretary shall also negotiate with manufacturers of insulin products to establish an MFP for insulin.

ACP's Position: ACP policy supports the ability of Medicare to leverage its purchasing power and directly negotiate with manufacturers for drug prices, although we have no policy on applying that same negotiating power to the commercial market and group/individual health insurance plans, as H.R. 1425 would do.

ACP also supports the repeal of the current law, known as the non-interference clause, which strictly prohibits HHS from interfering with negotiations between drug manufacturers and pharmacies and prescription drug plan sponsors. Absent repeal of the non-interference clause, we believe it should be modified to allow for this type of negotiation by the government for high-cost drugs in which Medicare has substantial financial interest as is included in this section of H.R. 1425.

CONCLUSION

ACP appreciate this opportunity to offer feedback on this important legislation and we look forward to working with you to advance these and other important reforms to enhance the ACA. We invite you to consider further recommendations from ACP as outlined in a recent series of position papers entitled, "Envisioning a Better U.S. Health Care System for All: A Call to Action by the American College of Physicians."

Sincerely,

Jacqueline W. Fincher, MD, MACP, President

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To: The Honorable Kim Schrier, U.S. House of Representatives, 1123 Longworth House Office Building, Washington, DC 20515

The Honorable Brian Fitzpatrick, U.S. House of Representatives, 1722 Longworth House Office Building, Washington, DC 20515

The Honorable Kathy Castor, U.S. House of Representatives, 2052 Rayburn Health Office Building, Washington, DC 20515

Dear Representatives Schrier, Castor, and Fitzpatrick,

As organizations dedicated to promoting the health of our nation, including children, pregnant women, and families, we write in support of the Kids' Access to Primary Care Act of 2020. Medicaid provides health insurance to 1 in 5 Americans, including many individuals with costly and complex health needs and nearly 40 percent of all children./1 Lower payment rates in Medicaid have historically created substantial barriers to accessing various health care services. Ensuring parity with Medicare payment rates will help eliminate these barriers and increase access to care for people with Medicaid coverage.

Medicaid is a critical part of our health care system. Medicaid covers some of the most vulnerable populations, including low-income children, pregnant women, and families, children with special health care needs, non-elderly adults with disabilities, and older adults. Medicaid is designed to meet the specific needs of these populations, providing access to necessary health services that include maternity care, pediatric services, behavioral health services, primary and dental care, specialized inpatient and emergency hospital services, and long-term services and supports.

As a result of these important services, Medicaid beneficiaries are less likely than those who are uninsured to postpone or forgo needed care due to cost, and less likely to have suffered a decline in their health in the past six months./2,/3 Medicaid coverage for low-income pregnant women and children has helped lower infant and child mortality in the U.S./4 Children enrolled in Medicaid are more likely than their uninsured peers to get medical check-ups, attend more days at school, graduate and enter the workforce./5 Simply put: Medicaid works.

However, even people covered by Medicaid may experience barriers to accessing care. A large body of research has shown that comparatively low payment rates are a substantial factor affecting physician participation in Medicaid. Medicaid payments for services are significantly lower than Medicare payments for the same services./6,/7 On average, a clinician treating a Medicaid enrollee is paid about two-thirds of what Medicare pays for the same services and only half of what is paid by private insurance plans./8 Primary care clinicians commit themselves to a long-term relationship with all their patients -- including Medicaid beneficiaries -- and provide not only first-contact and preventive services, but also the long-term care for chronic conditions that minimizes hospital admissions and reduces costs to the system. Increasingly inadequate Medicaid payments impede the ability of clinicians and other providers to accept more Medicaid patients, particularly among small practices, and threatens the viability of practices serving areas with a higher proportion of Medicaid coverage.

Congress took action to raise Medicaid primary care payment rates to Medicare levels in 2013 and 2014, with the federal government paying 100 percent of the increase. Access improved as a result: for example, the policy change led office-based primary care pediatricians to increase their participation in the Medicaid program./9 Unfortunately, lawmakers failed to reauthorize the payment increase after 2014. The Kids' Access to Primary Care Act would bring Medicaid payments for primary care services back in line with Medicare payment levels, while also expanding the list of eligible clinicians to ensure that people with Medicaid can access the care they need. The legislation would also help illuminate the impact of payment parity through a study of subsequent changes in Medicaid provider enrollment and payment rates.

Vulnerable populations need coverage that ensures them access to affordable and comprehensive quality care. When Medicaid beneficiaries cannot find a clinician who accepts new Medicaid patients, they face the same access problems as those who have no insurance. They are less likely to have a usual source of care, to forgo needed preventive and acute care for minor problems, to develop complications that require intensive and costly medical intervention, and to have poorer health status. Appropriate and adequate payment is essential to ensure the viability of the primary care workforce to provide such care. As such, we fully support the Kids' Access to Primary Care Act of 2020.

Thank you for your continued leadership in promoting policies that improve coverage and access to care. If you have any questions, please contact Stephanie Glier, Director of Federal Advocacy at the American Academy of Pediatrics, at [email protected].

Footnotes:

1/ Kaiser Family Foundation, Health Insurance Coverage of the Total Population, 2018 data, estimates based on Census Bureau's American Community Survey, 2008-2018. Accessed from https://www.kff.org/other/state-indicator/total-population/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D

2/ https://www.macpac.gov/wp-content/uploads/2015/01/Contractor-Report-No_2.pdf

3/ Amy Finkelstein et al., "The Oregon Health Insurance Experiment: Evidence from the First Year," National Bureau of Economic Research Working Paper 17190, July 2011, http://www.nber.org/papers/w17190.

4/ Andrew Goodman-Bacon, "Public Insurance and Mortality: Evidence from Medicaid Implementation," Journal of Political Economy 126, no. 1 (February 2018): 216-262. https://doi.org/10.1086/695528

5/ Medicaid and CHIP Payment and Access Commission. Use of Care among Non-Institutionalized Individuals Age 0-18 by Primary Source of Health Coverage, Data from Medical Expenditures Panel Survey. MACStats, 2018, https://www.macpac.gov/publication/use-of-care-among-non-institutionalized-individuals-age-0-18-by-primary-source-of-health-coverage-data-from-medical-expenditures-panel-survey/.

6/ Berman S, Dolins J, Tang SF, Yudkowsky B. Factors that influence the willingness of private primary care pediatricians to accept more Medicaid patients. Pediatrics. 2002;110(2 pt 1):239-248pmid:12165573, https://pediatrics.aappublications.org/content/110/2/239

7/ AAP Survey of Pediatrician Participation in Medicaid, CHIP and VFC. Elk Grove Village, IL: American Academy of Pediatrics; 2012. https://www.aap.org/en-us/professional-resources/Research/pediatrician-surveys/Documents/TX.pdf

8/ Kaiser Family Foundation, Medicaid-to-Medicare Fee Index, 2016 data, accessed from https://www.kff.org/medicaid/state-indicator/medicaid-to-medicare-fee-index/. Data sourced from Stephen Zuckerman, Laura Skopec, and Marni Epstein, "Medicaid Physician Fees after the ACA Primary Care Fee Bump," Urban Institute, March 2017.

9/ Increased Medicaid Payment and Participation by Office-Based Primary Care Pediatricians, Suk-fong S. Tang, Mark L. Hudak, Dennis M. Cooley, Budd N. Shenkin, Andrew D. Racine, Pediatrics Jan 2018, 141 (1) e20172570; DOI: 10.1542/peds.2017-2570: https://pediatrics.aappublications.org/content/141/1/e20172570

Sincerely,

Academic Pediatric Association

American Academy of Family Physicians

American Academy of Pediatrics

American College of Nurse-Midwives

American College of Obstetricians and Gynecologists

American College of Physicians

American Osteopathic Association

American Pediatric Society

Association of Maternal and Child Health Programs

Association of Medical School Pediatric Department Chairs

Children's Defense Fund

Children's Hospital Association

Community Catalyst

Families USA

Family Voices

First Focus Campaign for Children

March of Dimes

National Association of Pediatric Nurse Practitioners

Pediatric Policy Council

Primary Care Collaborative

Society for Adolescent Health and Medicine

Society for Pediatric Research

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