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September 15, 2021
US Health Care Reform
John E. McDonough
Jun 8, 2023
Aug 25, 2022
Jun 29, 2021
Back to The Milbank Quarterly Opinion
The massive shortcomings of the US health care delivery system have been strikingly evident during the COVID-19 pandemic. One key shortcoming involves the nation’s health care workforce—physicians, nurses, mental health professionals, and many others. To address this challenge, President Biden and Congress should establish a national health care workforce commission.
Some readers will now experience a déjà vu moment—didn’t we try that? Yes, creation of such a body was included as section 5101 of the 2010 Affordable Care Act (ACA). What happened to that ACA provision and to the intended body demands a new look.
During the ACA legislative process, the Workforce Commission was among its most bipartisan proposals. Senate and House Republicans and Democrats agreed that the nation faced serious health workforce problems and that such a commission was needed. Deep shortages in most professional categories were evident, if not nationally, then geographically. Many families were unable to gain access to many forms of needed medical help, and shortages affected every region of the nation, rural areas especially.
The proposed body became the crown jewel of Title V, the health care workforce portion of the ACA—the formation of a new national commission led by a nonpartisan and expert panel supported by professional staff that would collect and analyze data, and would formulate recommendations to improve the US health care workforce in multiple directions. Reports and recommendations were to be directed to the executive branch and Congress, and to be publicly available for states, counties, local communities, and the health care system at every level.
Other key portions of the ACA were considered politically at-risk from the get-go; for those, Congress included direct funding of them in the ACA with no need for annual appropriations. Because support for the workforce commission was so robust and bipartisan, no such treatment was deemed necessary by legislative leaders. The US Comptroller General who runs the Government Accountability Office (GAO) was charged with appointing the 15 members so that they could start work by 2011.
President Barack Obama signed the ACA into law in March 2010, and that fall the Comptroller General appointed the first members, an esteemed, experienced, and talented group of 15, to be led by Chairman-designee Peter Buerhaus, a nurse and health care workforce expert (then at Vanderbilt University and now at Montana State University). The requirements for appointment to the commission were set out clearly in section 5101 of the ACA:
“…national recognition for their expertise in health care labor market analysis, including health care workforce analysis; health care finance and economics; health care facility management; health care plans and integrated delivery systems; health care workforce education and training; health care philanthropy; providers of health care services; and other related fields;”
Shortly thereafter, things fell off the rails. Because the commission did not receive direct funding in the ACA, it needed to obtain an official appropriation from the US Congress before it could even meet. In the November 2010 mid-term federal elections, Republicans recaptured majority control of the US House of Representatives, eliminating Democratic “trifecta” control of the White House, Senate, and House for the remaining six years of the Obama presidency. Though President Obama included a $3 million budget request to Congress to enable the commission to get to work, the new House Republican majority viewed its election victory as a complete rejection of anything tied to “Obamacare.”
Commission members, who were legally prevented from convening, even by phone call, did their best to advocate for funding. Republican members, up to and including then-Speaker John Boehner (R-Ohio), expressed no reservations regarding the need for and legitimacy of the commission, but indicated that support would not be forthcoming because they could not support any part of Obamacare due to their public determination to repeal the entire law.
The terms of the original commission members were staggered so that one third would come up for reappointment each year. By 2014, all terms of original appointees had expired, and there was no more commission to fund or to seat. Never a front-page issue, discussion of the commission disappeared from sight. Still, the issues that made the commission a “no-brainer” in 2010 are just as urgent today. Read this description of key challenges written by Peter Buerhaus for Health Affairs in 2013:
“Among the most pressing issues are current and projected shortages of physicians (primary care physicians, general surgeons, and various specialty physicians); the persistent geographic maldistribution of the physician workforce; large expenditures on graduate medical education that do not appear to produce the physician workforce needed to address the population’s health care needs; looming shortages of registered nurses and other providers; chronic lack of access to health care for millions; and the need for innovation, greater teamwork, coordination, and quality improvement throughout the health care workforce.”
If COVID-19 has done anything, it has brought our health care workforce challenges back to the stage, front and center. As Naomi Cramer wrote for Becker’s Hospital Review on August 19:
“COVID-19 is surging again across the country, and frontline healthcare professionals in hotspots are facing overwhelming caseloads. The extreme and extended pressures of the pandemic will leave behind long-term changes to our workplace. … Clinicians are exhausted. Only 43 percent of registered nurses remain in bedside care. Many have left nursing altogether. Administrative staff and healthcare leadership are also struggling, and even those at executive levels have broken down under such enormous strain.”
A McKinsey survey from May of this year showed fully 22% of US registered nurses indicating an interest in leaving direct patient care within the next year. The explosion of interest in addressing workforce diversity and related equity issues is another rationale for establishing such an effort.
Some have likened the workforce commission to MedPAC, the Medicare Policy Advisory Commission, which advises Congress on matters relating to that federal insurance program—though not in a complimentary way. Over the years, MedPAC has gotten under the skin of more than a few important people and groups, inside and outside of government. One might suggest that, if they’re not getting under anyone’s skin, they’re probably not doing their job. It is inconceivable, for example, to address badly needed reform of graduate medical education without drawing blood. And it still needs doing. A MedPAC for the US health care workforce is a good idea.
Happily, if President Biden and Congress were to agree to re-establish such a commission, it would not be connected to the ACA, avoiding that political drag. And it certainly would be a pathway toward “building back better,” as the President continues to advocate. It was a good idea 11 years ago, and it’s a better idea now.
John E. McDonough, DrPH, MPA, is a professor of public health practice at the Harvard University TH Chan School of Public Health in the Department of Health Policy and Management. Between 2008 and 2010, he served as a senior adviser on national health reform to the US Senate Committee on Health, Education, Labor, and Pensions, where he worked on the writing and passage of the Affordable Care Act. Between 2003 and 2008, he was executive director of Health Care For All, a Massachusetts consumer health advocacy organization, where he played a leading role in the passage of the 2006 Massachusetts health reform law. From 1985 to 1997, he was a member of the Massachusetts House of Representatives where he cochaired the Joint Committee on Health Care. His articles have appeared in the New England Journal of Medicine, Health Affairs and other journals. He has written several books including Inside National Health Reform in 2011 and Experiencing Politics: A Legislator’s Stories of Government and Health Care in 2000, both by the University of California Press and the Milbank Fund. He holds a doctorate in public health from the University of Michigan and a master’s in public administration from the Kennedy School of Government at Harvard University.
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