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Health care and the new politics of vulnerability

From the November ACP-ASIM Observer, copyright 2001 by the American College of Physicians-American Society of Internal Medicine.

By Robert B. Doherty

Five weeks after the terrible events of Sept. 11, Washington remains a city on edge. Concrete barriers surround our most precious monuments, fighter jets patrol our airspace and trucks are banned from the blocks surrounding the Capitol building.

None of those defenses, however, prepared the capital for what has become the most disruptive threat: bioterrorism. Following the news that at least 30 Senate staffers in or near the office of Majority Leader Tom Daschle (D-S.D.) were exposed to anthrax spores from contaminated mail, Washington once again learned that the national government itself was—and remains—a target.

The anthrax exposure led to the closure of the entire House of Representatives, the virtual shutdown of the Senate and the suspension of mail service and public tours of the Capitol building. As Ronald Sarasin, president of the U.S. Capitol Historical Society, noted, "Terrorists succeeded in doing what invading forces, major international powers and even a bloody and protracted civil war all failed to do. They have disrupted the business of the federal legislature."

For Washingtonians, the reaction to the threat of terrorism is intensely personal; they know that they and their loved ones are at risk. But the reaction is also intensely political.

Congress has directed that the full power and resources of the federal government go toward homeland defense and national security. Everything else, no matter how high a priority before Sept. 11, is now considered less important.

The new health care agenda

Recent events mean that bioterrorism has supplanted the patient bill of rights, Medicare reform and patient safety as the top health issues in Washington. As the nation's priorities have changed, ACP-ASIM has reassessed its agenda and shifted attention toward public policy on terrorism-related health issues.

Advocating that Congress provide adequate funding for bioterrorism preparedness now is at the top of the College's advocacy agenda. We have written letters to Congress urging it to provide the full amount requested by the White House—$1.5 billion—to fund the CDC's bioterrorism preparedness plan.

In another letter to President Bush, the College urged that the federal government focus on the critical role primary care physicians would serve as the nation's first line of defense in detecting and reporting a potential incident of bioterrorism.

The College has made its communications resources available to the CDC to help disseminate practical clinical information to internists nationwide on the detection, diagnosis and treatment of possible bioterrorist diseases.

With the country's heightened degree of concern about foreign-born terrorists, the College also fears discrimination against international medical graduates (IMGs). In December, the ACP-ASIM delegation will take a resolution to the AMA's House of Delegates reaffirming the AMA's current policies against discrimination against physicians in employment or training based on their country of origin.

Advocacy for the uninsured

The College has not limited its advocacy efforts to the health consequences of terrorism. Lack of health insurance coverage was a problem before Sept. 11, and it is an even bigger problem now.

With the economy in recession, the ranks of the uninsured are expected to grow by hundreds of thousands. Individuals in the tourism and airline industries, which have experienced massive job layoffs since the terrorist attacks, are particularly at risk.

President Bush and key lawmakers are proposing modest steps to help those who have lost their jobs—and their health insurance. Legislation is pending to provide subsidies for individuals to maintain their group health insurance coverage under COBRA while they are between jobs.

Congress is also considering proposals to give states more money to maintain or expand coverage under Medicaid and the State Children's Health Insurance Program. This is a critical concern at a time when many state governments are cutting their budgets because of economic difficulties. ACP-ASIM supports efforts to boost coverage, although we recognize that they will likely help only a segment of the uninsured population.

Unfortunately, redirecting budget dollars and priorities toward national security makes Congress disinclined to spend the money needed to substantially reduce the numbers of uninsured Americans, even though most acknowledge the great need.

Advocacy for regulatory relief

Although most other health legislation risks being postponed, bipartisan legislation to ease Medicare hassles is making progress. The House Ways and Means and the House Commerce committees have both approved bills that will require carriers to provide accurate information to physicians; provide more resources to carriers for physician education; provide more due process in Medicare audits; and mandate pilot tests of alternatives to onerous documentation requirements for evaluation and management services.

ACP-ASIM was the only physician group asked to testify at a Sept. 26 hearing of the Ways and Means Committee on the bill, and many of our specific recommendations were incorporated into the legislation. Similar legislation is pending in the Senate.

Other issues

The fact that two key house committees approved regulatory relief legislation supported by the College is significant. These actions show that despite the shift in Washington's overall priorities, we can still make progress on other issues affecting internists. However, most other issues do not have the same degree of critical bipartisan support as the regulatory relief legislation.

Issues that might be postponed until next year include the patient bill of rights, because of partisan disagreements about patients' "right to sue"; prescription drug coverage through Medicare; establishment of a voluntary, confidential medical errors reporting system; and restored funding for teaching hospitals.

The current climate in which a sense of vulnerability makes national security the highest priority will not diminish in the foreseeable future. Sooner or later, though, Congress will need to address other risks to the public, such as medical errors and the lack of health insurance.

The College will continue to direct its advocacy efforts not only to the clear and present dangers of terrorism, but also to other risks for patients that result from misguided or inadequate federal policies.

Robert B. Doherty is ACP-ASIM's Senior Vice President for Governmental Affairs and Public Policy.

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