The ACEP’s Failure To Take A Position On Healthcare Reform
Last year when I interviewed then-American College of Emergency Physicians (ACEP) President Nick Jouriles I was disappointed that the ACEP had not staked out a clear position on healthcare reform. However, it wasn’t terrible that they didn’t have a position at that time, because the House bill was still being finished up and the Senate was still mired deeply in the fruitless “Gang of Six” negotiations. If ACEP wasn’t going to endorse reforms sight unseen, that was pretty reasonable, I thought. President Jouriles suggested that, in time, ACEP would weigh in with a position, one way or the other.
But we never heard ACEP take a position in the intervening months. So when I saw this post appear over at The Central Line, linking to this letter on the ACEP web site from ACEP’s current president, Angela Gardner, I was not surprised to see that ACEP has taken the weasel’s path and abstained from taking a position on the more or less final healthcare reform package. It’s pathetic, and brings into question whether ACEP can fulfill one of its most crucial functions: advocating for emergency room patients and advocating for emergency medicine physicians. The excuses offered by Dr Gardner for ACEP’s reticence to take a stand are fairly lame.
Specifically, she writes that this has been a continually shifting landscape for the last years, which is true enough, and she cites the “deep divisions” in opinion regarding the reforms, and instead offers up a vague set of principles which ACEP had previously laid out as its priorities in any reform bill.Which would be fine if the House was set to vote tomorrow on a vague set of principles. We’d be all over that! But for the actual reforms, sorry, ACEP couldn’t figure out, as an organization, whether it should support or oppose it. This is despite the fact that the broad outlines of reform have been perfectly visible for ages.Let me be clear: I wish ACEP had lined up with the AMA and the other medical societies like the AAFP, the ACP, and the AAP in favor of reform, but that’s because I support the reforms. But it would have been perfectly legitimate had the ACEP Council or Board joined the folks at the Texas Medical Association, the American College of Surgeons, or the Congress of Neurological Surgeons in their unapologetic opposition to the reform. I remember that in Dante’s Inferno — greatest piece of 14th-century Italian poetry I ever read — there was a special place in Hell for the Uncommitted, for those souls who, in life, couldn’t decide whether they supported good or evil. (Technically, they are outside the gates of Hell. Their punishment is to eternally pursue a banner while pursued by wasps and hornets that continually sting them while maggots and other such insects drink their blood and tears. Nice!) It’s sad to see an important organization like ACEP fall into this category of the pusillanimous and the timid when faced with the most important piece of health care legislation in our professional lifetimes.And remember, ACEP does not pretend that it has no role in politics. They aggressively market their political action committee, NEMPAC, with the goal of being the most influential specialty medical society. But when they come to me and ask for money, I will ask them, “where were you when health care reform was on the table? Why should I contribute my hard-earned dollars to an organization so feckless that it couldn’t even figure out its position on the bill that will impact our specialty more than any other law in three decades?” An advocacy organization that can’t figure out what to advocate for (or against) is pretty useless.And make no mistake, this bill has huge implications for Emergency Medicine. ER docs provide care for 20 million patients annually who have no insurance; the cost of providing care to the uninsured for EACH ER DOC is $125,000 per year in unreimbursed care. This bill promises to expand insurance to 31 million Americans — their care in the ER will now be funded. This will reduce our need to cost shift to private insurers, this will provide much-needed capital to expand overburdened ERs, and this will support recruitment and retention of skilled ER docs in underserved areas. Moreover, this reform will invest in community health centers and reimbursement for primary care, to give patients options to receive non-urgent care and follow-up care in settings more appropriate than the ER.Yet ACEP, historically dedicated to the parochial interests of EM, can’t decide whether this legislation is good for Emergency Department patients and physicians. It’s true that this has been a divisive debate, and there are many of us with strong opinions. However, my experience is that most ER docs that I personally know do have a great degree of confusion about the reforms proposed. Most ER docs (shockingly) don’t take time on their day off to read the CBO scores and delve into the policy details. This is why we have a professional society — this is why we have leaders. We rely on their expertise, we rely on their efforts to prise apart the statutes and the funding and come to a conclusion and lead the organization in a chosen direction. I don’t expect unanimity, and in fact for this issue I would expect a lively debate within the ACEP Council before a decision was reached — and consensus may indeed have been elusive. But this is why we have elections and why there are processes for reaching positions, and had Dr Gardner the courage to follow these processes to a resolution, ACEP would have been in a position to influence the national debate that has now reached a conclusion. Dr Angela Gardner and the other leaders of ACEP have failed in this obligation to their constituents.
*This blog post was originally published at Movin' Meat*
I wouldn’t dare to speak for why ACEP hasn’t addressed this issue. Perhaps it its trying to walk a fine line between academics (who typically are in favor of this reform package) and you’re average, working in the department, slugging it out for a living kind of doc. As one of the latter, let me say that most of the emergency physicians I know do not trust this legislation to benefit us. We have labored under EMTALA for over two decades. Yes, we all carry around a debt of about $125,000 per year due to unfunded care. But let me ask; who can we thank for that? The federal government, who graciously gave us the gig of providing free care, then decided that 1) paying for it wouldn’t be much fun and 2) protecting us from malpractice would be crazy-talk and 3) giving us the amount in tax-deductions would be simply currying favor with the ‘rich.’ If they will do that, for 20 years, what makes anyone think that this new package will help us make money? We’ll be overwhelmed because there aren’t enough primary care docs. We’ll be overwhelmed because PMD’s will send us their overflow. We’ll be overwhelmed because NP’s and PA’s (the new primary care) will send us what they can’t handle. And we’ll be overwhelmed because for 20+ years, everyone has learned that going to the ED is the path of least resistance. More money? Sure, for a little while. Then someone at HHS will say, ‘yikes we’re paying those ER guys a lot! Dial that down and send it over to another specialty! And look around for some more fraud, waste and abuse!’
Edwin