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Most important election ever

Parties make different promises about health care’s future, but some changes have bipartisan backing

By Richard Nelson, managing editor, October 1, 2012

The phrase is a cliche. Every two or four years, politicians seeking office (and raising money) and pundits seeking viewers declare that the results of this election, perhaps more than any other, will determine the course of the future. But for physicians wondering about the future of the American health care system, there is more truth to the phrase than usual this time around. With the future of the Affordable Care Act (ACA), 2010’s health system reform law and the most sweeping change in the health care landscape since the enactment of Medicare, very much in play, dermatologists and their advocates in Washington, D.C., agree that this election will determine whether and how that law is implemented and have major impact on dermatology’s key legislative priorities. But they also caution that some of the ideas the law contains, including care coordination, shared cost savings, and electronic record keeping, are likely here to stay regardless of who wins.

Fate of IPAB

When the American Academy of Dermatology Association made a list of its key legislative priorities this summer, eliminating the Independent Payment Advisory Board (IPAB), a panel of 15 appointed officials created by the ACA to rein in Medicare spending, was one of the top three items. This status reflects IPAB’s role as a chief sticking point for the AADA during the legislative process. Dermatologists are not alone in viewing IPAB as a problem, according to Sabra Sullivan, MD, PhD, chair of the AADA’s Congressional Policy Committee. “We’re not the only specialty concerned about this,” she said, and suggested pushing for IPAB repeal may be an opportunity to work with other groups in medicine.

Shawn Friesen, the AADA’s director of legislative, political, and grassroots advocacy, agreed that there is broad-based concern about IPAB and noted that it crosses the aisle. “This could be a very interesting fight,” he said. “There are court challenges percolating that contend that IPAB would take a congressional function and move it to the executive branch. By surrendering that power, the question becomes, is that allowed under the constitution?” IPAB has faced bipartisan opposition, particularly in the House, he noted. “In addition, IPAB was a significant issue during consideration of the ACA. The concept, which originated in the Senate and was supported by the White House, faced considerable opposition by House Democrats.”

Even if IPAB repeal does not go forward because a Democratic Senate or a re-elected President Obama block it, there are scenarios under which the board could fail to gain traction. “IPAB appointments could fail to get cloture in the Senate [the 60-vote threshold for clearing a filibuster], which would be an interesting scenario,” Friesen said. “Will the White House appoint acting members? Will Congress defund it? It could be one of the more fascinating fights.” (For more details on how IPAB is supposed to work, visit Dermatology World online at Similarly, as long as Republicans retain control of the House, they are likely to fight approval of funding necessary for some aspects of ACA implementation, Friesen noted.

Medicare physician payment

Another top legislative priority for the AADA is Medicare physician payment, specifically finding a permanent replacement for the sustainable growth rate (SGR) formula, which dictates a 27 percent cut in payments to physicians in 2013. According to Sandra Read, MD, chair of the AADA’s political action committee, SkinPAC, partisan politics plays less of a role here than the difficult math of a fix. 

“We need a permanent SGR fix to ensure access to care for Medicare patients. If we can’t afford to practice, we’re not there,” Dr. Read said. But, she added, “I don’t think the SGR is really going to be affected much by who’s in control after the election. This is a larger issue than Republicans and Democrats. There are questions about how to regulate; there may be changes in reimbursement for doctors, increased taxation to recipients; the beneficiaries’ benefits might be reduced.” But both parties, she said, have recognized that such a draconian cut in payments would devastate the Medicare program and its beneficiaries.

The methods used to close the budget gap created by the SGR, as well as a further gap created by the Budget Control Act (part of the agreement that ended 2011’s debt ceiling battle), could also differ depending on which party is in control, according to Friesen.

“Those varying approaches will impact what happens for providers and patients — if you’re not collecting more money from patients, you’re more likely to have to decrease Medicare physician payments,” Friesen said. In addition, the potential expiration of the Bush tax cuts at the end of 2012 could put revenue on the table, he added, “but you still have a fight over being able to use those funds that would come into play. It may show up on the ledger sheet but there would still be policy fights.”

Indoor tanning and possible regulatory slowdown

If the Academy’s IPAB concerns would seem to lean Republican and Medicare payment is somewhat neutral, its goals for another top priority, indoor tanning and skin cancer prevention, are expected to fare better under a Democratic administration. While a Republican sweep might wipe out IPAB or even the entire ACA, it could take some tanning regulations with it.

“Romney’s election to the White House could really hold up the release of the indoor tanning regulations, if they are not released before the election,” according to Leslie Stein Lloyd, JD, the AADA’s director of regulatory and payment policy. “These regulations are likely to be controversial with the tanning industry and small businesses, and would be more likely to get through the Office of Management and Budget in the Obama administration than in Romney’s.” Additionally, she said, “If Romney is elected and/or the Republicans take control of Congress, we can expect to see a push to repeal [all or parts of]the Affordable Care Act, which would impact a tremendous number of regulations already in the works,” including those related to biosimilars and the 10 percent tax on indoor tanning that the AADA pushed to have included in the law.

However, she noted, some things would not change. “I think the Romney White House and/or a Republican Congress would likely continue the push toward integrated care models, episodes of care, and bundled payments,” Lloyd said.

A change in the administration would probably grind business to a halt in D.C. in the short term, Lloyd said; this often happens when one party takes over from the other.

“While who is in the White House and on the Hill impacts the implementation of regulations, changes in the administration are significantly impactful on the regulatory process across the board, and across all issues and agencies. A change in the White House would likely prompt a turnover of political appointees at the agency and department level, which takes a toll on the efficiency of agencies,” she said. Also, “A new administration would likely freeze the release of all regulations. This kind of turmoil would impact the rate of making regulatory changes for at least six months.”

Bipartisan advocacy strategy

Given that it has support for some of its issues on both sides of the aisle, dermatology must maintain a bipartisan advocacy stance, according to Marta VanBeek, MD, MPH, chair of the Academy’s Council on Government Affairs, Health Policy, and Practice. “We always advocate in a bipartisan manner,” she said. “We choose the issues that matter to our patients and our specialty and work with members of Congress who share our position on them.” (SkinPAC takes a similarly bipartisan stance; see sidebar.)

In the run-up to the election, key Academy committees and staff are considering what to do depending on the election results, Dr. Sullivan said.

“We’re exploring how to move forward with our priorities and how we need to prepare Academy members for what may come,” she said. “The priorities are the same; the question is how to achieve them. Even if Republicans win everything, repealing is easier said than done. What will we do if the individual mandate goes into effect? We’re looking at every contingency.”

Dr. Sullivan noted that while the ACA is law after being upheld by the Supreme Court, much of the regulation that will give it life has yet to be written. “In talking with different people in my state, there’s a sense that although there’s a law even the people at the very top who are making the decisions are finding that there’s much that has not yet been interpreted. We know the different scenarios but we don’t yet know the whole picture of what they will be.” Until the election, she added, “we won’t know who we’re going to be dealing with in the next stage of the process.” But she promised dermatologists that “as things unfold, you’re going to see a lot more action; no one is twiddling their fingers. There’s lot of discussion, and action plans are being developed depending on what happens. We’re evaluating where opportunities for dermatology will lie depending on the scenario. You can bet that all of us who are working on this haven’t given up on trying to achieve what we need for our specialty.”

Some change is here to stay

While continued advocacy will affect the law’s implementation, dermatologists would do well to be realistic about the degree to which changes that may be referred to under the broad umbrella of “reform” are unrelated to the fate of the ACA, according to Jack S. Resneck Jr., MD, associate professor and vice-chair of dermatology at the University of California San Francisco School of Medicine.

“Many of the changes in health care delivery that will ultimately affect our practices are being driven by both private insurers and public payers, and would continue to move ahead whether the ACA had been upheld or struck down,” he said. “There is momentum to increasingly base payments on quality measures, drive full adoption of electronic health records, and incentivize integration of practices. Our specialty will have to actively seek ways to demonstrate the quality we offer and fit into the evolving system in order to preserve and enhance our ability to care for our patients.”

Dermatologists will have to make their voices heard to ensure that their important role is recognized as changes are implemented, Dr. Sullivan said. “I don’t think you’ll find any dermatologist who isn’t trying to help cost-save or be a diligent steward of our medical resources,” she said. “Dermatology is a unique specialty, one that is very fiscally efficient in that you can receive complete medical care for your skin in an economical model. We as dermatologists really help bend that cost curve the right way.” Advocates for the specialty will continue to make that argument, she said, regardless of who wins the election in November. “The bottom line is that we’re going to be fighting tooth and nail to maintain access for patients, to be able to maintain our practices and protect all aspects of our practice, so that people can continue to deliver the best care possible for their patients.”

Additional Dermatology World Resources