In this segment of Medscape One-on-One, US Rep. Karen Bass (D, California), a physician assistant representing the state of California, talks with Dr. Eli Adashi about physician and nursing shortages, Medicare and Medicaid reform, and why physician reimbursements need to be higher.
Dr. Adashi: Hello. I am Eli Adashi, Professor of Medical Science at Brown University and host of Medscape One-on-One. Joining me today is Karen Bass, a physician assistant by background who is presently serving in the US House of Representatives on behalf of the 33rd Congressional District of the State of California. Welcome.
Rep Bass: Thank you.
Addressing the Primary Care Shortage
Dr. Adashi: We are really privileged to have somebody such as yourself, who is a provider-legislator. I thought we would start with an issue that clearly troubles all of us, and that is the relative shortage of primary care providers and the notion that perhaps we could address this issue by introducing, promoting, and enhancing the contribution of other healthcare providers beyond physicians. I was wondering if you could share with us your thoughts about it, given your unique background and given that we really have a challenge on our hands.
Rep Bass: Absolutely. We have a challenge, and we have an incredible opportunity. I remember a couple of years ago, when healthcare reform was being debated and everybody was talking about expanding coverage to 30 million people who were uninsured; frankly, the first thing that came to my mind was, who's going to provide the care? It's been many years since I was in clinical medicine, but when I was in clinical medicine, we had an incredible shortage then.
I remember nurses being recruited from the Philippines and from Canada. I remember having to serve double shifts and fill in 5 or 6 extra days a month because we had a shortage, and now we're talking about expanding coverage. So I think our challenge is, how do we do it with the current workforce? The opportunity is that it creates a jobs program. We need to hire, we need to train, and we need to recruit. And then, one of the things that's most important that we need to do to expand the workforce is to figure out how young people and career changers, who might be a little older, are going to be able to afford the extra training that's needed so that they can participate in the healthcare field.
Funds for Expanding the Healthcare Workforce
Dr. Adashi: Can we point to segments of the Affordable Care Act (ACA) wherein the very concept of using a multitude of healthcare providers is embraced? Are there sections where the need for funds for further training is emphasized?
Rep Bass: I think there are a couple of places where it is emphasized. First of all, the ACA's focus on prevention lends itself to expanding the healthcare workforce. Of course, I want to promote midlevel practitioners -- physician assistants and nurse practitioners -- who can play that role in expanding primary care, because when you're talking about prevention, you are primarily talking about primary care people who practice in the field.
The ACA's emphasis on prevention is one place where these subjects are addressed, and there are 2 other places. One section called for forming a work group that will look at the healthcare workforce to better understand the needs. Unfortunately, because of partisanship and the commitment of some to repealing the ACA, that part of the act has not been appropriately funded. We do need to have a workgroup that looks at the long-term need of how to expand the workforce.
The other place that I would point to is the part of the act that called for the formation of the Centers of Innovation. I've been talking with many practitioners in my community who have submitted proposals for innovative ways of providing healthcare in areas where there's a great need.
Support for Nurse-Led Clinics
Dr. Adashi: I believe at least a modest amount of support has been assigned through the ACA to nurse-led clinics. It is probably more of a demonstration project, given the amount of funds that have been allocated, but in broad strokes, what is your outlook on an initiative to use physician assistant-supported or staffed clinics to help offset the primary care shortage?
Rep Bass: I think we're a little stalled right now, but the part of the ACA that was already funded and passed prior to this particular Congress is moving forward. In terms of any additional programs or additional funding for nurse-led clinics, I believe we're in a holding pattern right now. I'm optimistic that holding pattern won't last beyond this year, but I do believe that's where we are right at this moment.
Nursing Representation in the Surgeon General's Office
Dr. Adashi: We've been given to understand that there is a nursing bill in the works that among other things seeks representation of the nursing profession in the Office of the Surgeon General. Where do you stand on that issue? How do you feel about that as a need to complement what has traditionally been a physician-dominated office?
Rep Bass: Well, I always support expanding because to me, when I think of expanding, I think of providing care in areas that are underrepresented and underserved. So I think that's a fine idea, and I hope it expands beyond nurses as well.
Supreme Court Deliberations on the ACA
Dr. Adashi: I can't help but reflect on the deliberations in the Supreme Court regarding the ACA. You must have watched this with equal interest. Would you care to share a few of your most prominent thoughts on what transpired and perhaps what's ahead?
Rep Bass: I am not a lawyer, so I have to say that and what I have heard from people who are lawyers and have experience in arguing cases before the Supreme Court is that you can't judge what the outcome of the court decision might be on the basis of the arguments. If you think about it, this was the first time we actually heard arguments. It might have been a lot better if we saw it.
I have to be optimistic and believe that you can't judge what the outcome will be on the basis of how the arguments went. I think we really don't know. It will be June when it happens, and if it happens in a way where the individual mandate is struck down, I don't believe the overall bill will be thrown out.
Medicare and Other Safety Nets
Dr. Adashi: Let me turn to Medicare and other safety nets. As we look at the current scene, it would seem that 2 opposing views are in conflict. On the one hand, we have the ACA and the administration's vision for Medicare. On the other hand, we have the proposals by Congressman Paul Ryan, Chairman of the House Budget Committee. What can you tell our viewers about the fundamental differences between these 2 approaches, and where this might lead us this year or potentially beyond?
Rep Bass: You are polite in describing it as 2 different worldviews, because that can't be emphasized enough. I think that it's important that people read Congressman Ryan's budget proposal, The Path to Prosperity: A Blueprint for American Renewal. I happen to believe that in our country, which is the richest nation on the planet, we should be able to figure out how to provide for those who are least able.
When I look at children, seniors, disabled persons, and so on, essentially what Paul Ryan is calling for is taking away the guarantee that when you turn 65 or if you are disabled, we will provide healthcare for you. He believes in taking this and turning it into a voucher that I would hand somebody when they become 65, and I would say here's your $1000 check, let me shake your hand, now go find health insurance.
The problem is that [Ryan] believes in repealing the ACA. If you repeal the ACA, you cannot guarantee that if you have a preexisting condition, you will be able to find health insurance to cover you. What is your $1000 check going to buy you then? And if you have a major problem after you've spent that check, then what? I believe that our country has the type of wealth to guarantee people who are seniors and people who are disabled that they will receive healthcare. With Medicaid, Congressman Ryan wants to take Medicaid and give the $1000 check to a state.
Dr. Adashi: The so-called block grant.
Rep Bass: Yes. Take California, for example. If California were given a fixed amount of money to provide healthcare for the poor and for people in nursing homes (because Medicaid also pays for nursing homes), what happens when California goes through a recession and tens of thousands of people lose their jobs? What's the first thing that happens when you lose your job? You lose your healthcare.
If you give a state a fixed amount of money to provide healthcare and there is an emergency or a change in the economy, that state literally runs out of money. So it's 2 views: One says survival of the fittest, and the other says that the richest country on the planet in the history of the world should be able to prioritize healthcare and other resources for people who might fall through the cracks.
A Fix for the Sustainable Growth Rate Formula?
Dr. Adashi: As you can imagine, our physician providers continue to be concerned about future reimbursement on the Medicare as dictated by the sustained growth rate formula. We've gone through many years during which we have postponed or avoided a permanent fix. Everybody is curious as to what would happen next and if so, when?
Rep Bass: First of all, I believe that the reimbursement rates need to be higher -- significantly higher -- and I also believe there should be a permanent fix. I don't think that this issue should reach a crisis point almost on an annual basis, where we're getting close and we have to do what we call "the doc fix." Let's make sure it doesn't run out. First of all, I am convinced that it will not run out, that we will continue in this crisis mode for a while until things change in the Capitol. But if you fundamentally change Medicaid and Medicare in the ways that the Ryan proposal calls for, then we are going to be in a perpetual state of crisis. So there needs to be a permanent fix, and reimbursement rates need to be significantly higher.
Healthcare Under "President Romney"
Dr. Adashi: Subject to the usual limitations in foretelling the future, what would be your best prediction as to how healthcare would look under President Romney, were he to be elected?
Rep Bass: If Romney is elected president, it also is contingent on whether or not the Republicans would be in control of the Senate or the House. Let's just say that happens. If all 3 happen, then I think healthcare reform would be repealed. I think Medicaid would be block granted, and I think that Medicare would be turned into a voucher system. Because I have read The Path to Prosperity -- and I encourage people to read Paul Ryan's document -- I think that if that were enacted, it would fundamentally change our country, and it would change our country in a fashion that essentially would leave lots of people falling through the cracks.
Dr. Adashi: In other words, if that were all to transpire, it's far more than just a physical change in our policies and in the safety nets we have in place. It's really a change in world outlook.
Rep Bass: It is a fundamental change in our country, and I think that it's a cynical one.
Life in the Emergency Department
Dr. Adashi: If I may close on a personal note, many of us admire the fact that a provider such as yourself has taken on public service. Could you perhaps trace for us briefly the events that ultimately encouraged you or directed you toward public service?
Rep Bass: I was always involved in public policy and politics from the time I was a child. This happened because of the period that I grew up in. It was the 1960s and the 1970s, when lots of people were involved in public policy. But from the point of view of a provider, I worked for several years in Los Angeles County's trauma unit, in the emergency department (ED). I would see people come into the ED day in and day out, and I was fixated on what drove them there in the first place.
I liked the instant gratification of being able to fix someone and send them on their way, which is different from dealing with a chronic disease. But on the other hand, I was very driven by why they were in the ED to begin with. Everything we've been talking about these last few minutes is an example of that: They were in our ED because they didn't have healthcare. They were in there because they had substance abuse problems and they didn't have treatment options. So, the social and health issues that drove those people to the ED is what drove me into a career in public policy.
Dr. Adashi: On that note, sincere thanks to Rep Bass and to you, our viewers, for joining Medscape One-on-One. Until next time, I am Eli Adashi.