Gastroenterologists as Advocates In a Changing Policy World

Experts gathered to discuss policy changes and their impact on digestive research and patient care during the “Gastroenterology in the Age of Trump” session presented by the American Gastroenterological Association (AGA) at Digestive Disease Week 2017, held May 6-9 in Chicago, Illinois.

The first speaker, Spencer Dorn, MD, MPH, MHA, associate professor of medicine at the University of North Carolina Center for Functional GI & Motility Disorders, acknowledged that health policy can be a contentious topic, but virtually every stakeholder regardless of political leaning understands the complexity of healthcare reform. He attributed this to the “policy trap,” first hypothesized by author Paul Starr, which makes change “extraordinarily difficult.”

In 2008, the Democratic party platform stated that all Americans should be guaranteed healthcare, and President Barack Obama attempted to fulfill that ideal through the Affordable Care Act (ACA), which had major goals of insurance expansion, insurance regulation, and delivery system experiments. However, the individual markets were plagued by issues like unbalanced risk pools, and the law’s unpopularity eventually swept the Republicans into power in the House and Senate.

The Republican party platform in 2016 advocated for returning healthcare to citizen control instead of “the forces of centralized social planning” represented by the ACA. When President Donald Trump was elected in November, Dorn said, it represented a “ground-sweeping opportunity for them to realize a lot of the policy ideas they’ve had for years.”

Those policy ideas, like eliminating the individual mandate and rolling back Medicaid expansion, are reflected in the American Health Care Act (AHCA), which was passed by the House last Thursday. Dorn does not personally believe the AHCA will pass the Senate, due to budget reconciliation rules, a recent uptick in the popularity of the ACA, and “united stakeholder opposition” from leading medical groups. However, regardless of the future of the AHCA, the payment landscape is shifting as insurers redesign benefits and gastroenterologists encounter pressure to demonstrate value and efficiency. Constant in this equation, Dorn said, is the idea that “the ultimate concern is cost.”

Costs are a major concern not only for practicing gastroenterologists, but also in medical research, explained the next presenter, Folasade (Fola) May, MD, PhD, MPhil, assistant professor of medicine in digestive diseases at the University of California, Los Angeles. May outlined how the Trump administration’s personnel choices, proposed budget, and policies could potentially impact funding for the National Institutes of Health (NIH) and research as a whole. Trump’s proposed “skinny” budget would cut $5.8 billion in funding from the NIH, which May said could discourage young scientists from pursuing academic careers and lead to laboratory staff being laid off or research projects left unfinished.

“However, there is hope,” May said. She explained that there is widespread bipartisan support in Congress for biomedical research, as evidenced by the recently approved budget for the remainder of the 2017 fiscal year, which included a $2 billion funding increase for the NIH. Observers are waiting to see what the full 2018 budget will entail, but in the meantime, May said that “the message throughout the scientific community is that we all need to get informed, engage in advocacy, and speak up.”

The next presenter to speak up was John Allen, MD, MBA, AGAF, clinical professor of medicine in the University of Michigan Health System’s gastroenterology division, who discussed how gastroenterologists can impact clinical and research policy. He warned that compared with the younger panelists Dorn and May, “I’m at the end of my career, so I don’t have to hold back.” He criticized the AHCA, which he said “eviscerates Medicaid,” and predicted that academic medical centers should expect reduced discretionary spending “in the Trump age.”

Amidst these pressures, Allen said, the most important thing practitioners can do is to be informed. He encouraged them to educate themselves on how government works and gather information from think tanks all along the political spectrum. In the virtual age, there are unlimited opportunities to learn and become involved, like by participating in the AGA’s community discussion forums. Allen told the audience to join advocacy efforts and make their voices heard, no matter what their political opinions, because “you either have to be part of the solution or you’re going to be part of the problem,” quoting activist Eldridge Cleaver. “Our patients need you, so please don’t sit back,” Allen added.

An audience member asked the panel how to get other clinicians and the AGA as an organization to recognize the importance of policy issues, noting the relatively sparse attendance of the session. May recommended spreading awareness on social media, starting discussions with colleagues, and participating in advocacy events, while Allen urged gastroenterologists to run for political office.

Another attendee asked how the panelists envisioned the future roles of hospitals and academic institutions in light of the rapidly shifting incentive structures and payment models. Dorn said he expects these entities to face intensifying cost pressures and an increase in uncompensated care, which will threaten their ability to conduct research, provide clinical services, and educate the next generation of clinicians, but ultimately, the field will have to adapt to the times. “We have to redefine the value proposition for our patients if we’re going to survive,” he concluded.