Higher education, and particularly people and colleges involved in medical training, have a lot at stake in the sweeping health-care legislation that Congressional leaders are expected to continue wrangling over this week.
They are trying to save the embattled legislation in the wake of last week’s Republican upset in the hotly contested race for the U.S. Senate seat previously held by the late Edward M. Kennedy.
Republicans have been fighting the proposed health-care overhaul, which would extend coverage to more than 30 million people who are now uninsured. The Democrats’ loss of the 60th seat they needed to overcome a Republican filibuster in the Senate threatened to derail the plan’s chances for passage. It also jeopardized prospects of reaching a compromise between the bill that passed the House of Representatives, known as the Affordable Health Care for America Act (HR 3962), and the one that passed the Senate, the Patient Protection and Affordable Care Act (HR 3590). Democrats would like to have a compromise bill approved by early February.
Here are some key issues that officials at universities, medical schools, and other health-care programs in academe are watching closely as lawmakers struggle to reconcile their differences.
TEACHING HOSPITALS
Subsidies. Hospitals that train doctors and other health-care workers are worried about potentially drastic cuts in the Medicaid and Medicare “disproportionate-share payments” they have been receiving. Those payments help compensate hospitals that serve as safety nets for the extra costs they incur caring for patients who are poorer and sicker than people at other hospitals.
The Association of American Medical Colleges reports that its teaching hospitals provide 41 percent of indigent care, even though they represent only 6 percent of acute-care hospitals. Because of that, those hospitals have been receiving billions of dollars a year in supplemental payments from Medicaid and Medicare. Lawmakers who approved the cuts in those subsidies reasoned that, with about 95 percent of Americans covered by insurance under the bills to overhaul the health-care system, the burden on teaching hospitals would be far less.
The medical colleges’ association counters that those facilities would still end up caring for patients who fall through the cracks, and for the nation’s approximately 12 million undocumented immigrants, who would not be eligible for insurance under the Senate bill. The House bill would allow undocumented immigrants to buy polices through new government-regulated exchanges. (Any final legislation that emerges is expected to more closely resemble the Senate version, which is less expensive than the House bill.) People who caution against slashing subsidies for teaching hospitals argue that uninsured people could still end up crowding into their emergency rooms, which have to treat patients regardless of their insurance status.
The House bill would cut Medicaid disproportionate-share payments by $10-billion over 10 years and Medicare payments by $10.3-billion over 10 years. The Senate bill would slash Medicaid payments by $18.5-billion and Medicare payments by $24.4-billion over that period.
“Innovation zones.” Teaching hospitals would benefit from an option in the Senate bill, which is not included in the House version, that would set up a pilot program in “health-care innovation zones,” geographic regions that include a teaching hospital, physicians, and other clinical groups. The entities that collaborate as part of these zones would jointly provide a full range of health care with the goal of cutting costs and improving quality. Participating hospitals could experiment with new types of clinical approaches for training health-care workers in an environment that encourages collaboration among different professions.
The U.S. secretary of health and human services, Kathleen Sebelius, would award 10 to 25 grants, worth between $250,000 and $1-million each, to teaching hospitals or other health-care providers to study and prepare a plan for a health-care innovation zone. The secretary would test a few of those proposals in a three-year demonstration project in which participants would be exempted from certain legal and regulatory barriers that inhibit collaboration.
MEDICAL SCHOOLS
Resident training. Both bills have provisions that support residency programs in primary care and general surgery, two areas in which shortages are predicted. But many medical educators were disappointed that the bills did not include a Senate amendment that would have increased by 15 percent, or about 15,000 positions, the total number of residency slots paid for by Medicare. Those numbers have been frozen since 1996.
The Association of American Medical Colleges argues that without such an expansion, the number of physicians per capita will continue to drop over the next decade as millions more people have access to health insurance and older doctors retire. The association is already predicting a shortage of at least 125,000 physicians by 2025. Medical schools are expanding class sizes and new ones are opening, but without more postgraduate training slots, a bottleneck could stifle expansion efforts, supporters of the amendment say.
But skeptics of the need for the 15,000 new slots counter that the problem is the distribution, not the total number of doctor trainees. They favor incentives to promote a shift toward more residents training in primary care and practicing in underserved rural and inner-city areas, without an overall expansion in the work force. Both the House and Senate legislation would do that by allowing about 1,000 unfilled residency slots to be reassigned for primary-care trainees. The American Medical Student Association contends that expanding total residency slots would just encourage more foreign medical students to leave countries where their services are needed to train and practice in the United States.
Student debt. Both bills include debt relief for medical-school graduates who, on average, start out owing about $155,000 in student loans. Proponents say such assistance is crucial if the nation is to beef up the number of primary-care doctors, who generally earn less than people who pursue other specialties. Both the House and Senate bills would expand the National Health Service Corps, which offers scholarships and loan-repayment programs for medical-school graduates who agree to practice in medically underserved communities for a specified length of time.
The Senate bill would authorize an allocation of $1.2-billion to the corps by 2015, with the potential for $1.5-billion in supplemental funding. The House bill would award the service corps an additional $350-million over five years, as well as $1.4-billion over five years for scholarship and loan repayments.
Similar incentives would be expanded under both bills for graduates of programs in nursing, public health, and other health-care fields in high demand.
Training outside hospitals. Provisions in both bills would make it easier for medical residents to train in nonhospital settings, like community health centers and rural clinics. Supporters point out that more and more care is being provided in outpatient clinics, where preventive treatment is stressed. They favor provisions in the bills that provide direct medical-education payments for time that trainees spend in outpatient settings. Regulatory barriers, including strict government accounting requirements, now discourage programs from sending residents to those outpatient settings.
Training more residents in community centers could encourage more young doctors to go into primary care, easing the primary-care shortage, supporters say.
NURSING SCHOOLS
Faculty shortages. One of the biggest challenges in staving off a predicted shortage of nurses is finding enough nurses with advanced degrees willing to accept a pay cut to teach in the nation’s nursing schools. Faculty shortages have forced many nursing schools to turn away thousands of student applicants a year. Provisions in both bills would expand existing loan-repayment programs to include nurses who agree to teach in accredited nursing programs.
A separate provision in the Senate bill would forgive up to a total of $40,000 in graduate-school loans for nurses who receive master’s degrees and go into teaching, and $80,000 for those who receive doctorates to pursue teaching careers. To be eligible, nurses must teach for at least four years during a six-year period after they graduate.
HIGHER EDUCATION IN GENERAL
Student insurance. Some campus health officials and higher-education groups are hoping that any legislation that finally emerges will include a provision that they say would allow colleges to continue offering low-cost health-insurance plans to their students. The provision they advocate would continue to exempt the kinds of health-insurance plans that colleges usually offer from some federal regulations on individual health-coverage plans.
The House version includes that provision, but it was left out of the Senate bill. Some groups, including the American Council on Education, have warned that students could end up paying much higher premiums than they now do if colleges are forced to open up student plans to anyone who applies, even if he or she is not affiliated with a college. The way the Senate bill is written, a common rating would be applied to the covered group regardless of a person’s age or health status. That means younger, healthier consumers like college students would have to subsidize the health-care costs of older, sicker plan members.
Taxes on insurers. Employees who receive generous health-insurance plans might be affected by a tax on insurers offering expensive plans. Those costs would probably be passed on to the people who are insured in the form of higher premiums. The goal of the “Cadillac tax,” which is included in the Senate bill but not in the House version, was to raise money to help pay for the health-care overhaul and to rein in skyrocketing health-care costs. But powerful opposition to the idea from labor unions forced Congress to compromise. During negotiations this month, Congressional leaders reached a tentative deal in which they raised the threshold for the tax to kick in to plans that cost $24,000 or more for a family and $9,000 or more for an individual. They also agreed that unions (including those representing faculty members) and public employees could be exempt from that tax until 2018.
State budgets. Education groups have also appealed to lawmakers to help insulate colleges and student-aid programs from state budget cuts that might result from the higher Medicaid costs states are expected to face if Congress passes a health-care bill. In a letter sent this month to key lawmakers, the American Council on Education cited studies by the White House Office of Management and Budget that show that as states’ share of Medicaid costs increase, their spending on public higher education, including financial aid, drops. The letter applauds lawmakers’ decision to provide federal subsidies to help offset those costs through 2016, and it appeals for “additional ways to insulate states from increased Medicaid costs in the future.”
HIGHER EDUCATION AND DRUG COMPANIES
Conflicts of interest. Both bills have provisions aimed at cracking down on conflicts of interest in continuing medical-education courses, which physicians must complete to maintain their licenses. Drug and medical-device manufacturers would be required to disclose information about gifts, consulting fees, or other payments they have made in connection with such courses.
The Senate bill would require manufacturers to disclose such gifts to physicians and teaching hospitals, while the House bill would require disclosures to other groups, too, including pharmacists and medical associations. Authors of the legislation seek to ensure that patient care is based on the best science, not on the amount of money that drug and device makers have paid to sponsor courses.
Exclusive rights to drugs. Both bills would give commercial drug companies 12 years of exclusivity to sell certain drugs and vaccines they develop from inventions coming out of university laboratories. The American Medical Student Association has been fighting that provision, which it says would raise health-care costs by delaying the introduction of cheaper generic versions. But several powerful pharmaceutical companies threatened to withdraw their support for the overall health-care legislation if that protection period were reduced. The Association of American Universities, which represents 60 leading public and private research universities in the United States and two in Canada, says the 12-year period would ensure that drug companies continue the high-risk business of making new biologic drugs, which are derived from living cells, and can recover their costs before copycat drugs are introduced. Current law offers no legal pathway for companies to make generic biologics, so companies that manufacture them have an indefinite monopoly.
