20 March 2010

ACEP's Staggering failure of leadership

I was disappointed when I interviewed then-ACEP President Nick Jouriles last year that ACEP had not staked out a clear position on health care reform.  However, it was not terrible that they did not have a position at that time, because the House bill was still being finished up and the Senate was still mired deeply in the fruitless "Gang of six" negotiations.  If ACEP was not going to endorse reforms sight unseen, that was pretty reasonable, I thought.  President Jouriles suggested that, in time, ACEP would weigh in with a position, one way or the other.  But we never heard ACEP take a position in the intervening months.

So when I saw this post appear over at The Central Line, linking to this letter on the ACEP web site from ACEP's current president, Angela Gardner, I was not surprised to see that ACEP has taken the weasel's path and abstained from taking a position on the more or less final HCR package which is going to a vote tomorrow in the US House.

It's pathetic, and brings into question whether ACEP can fulfill one of its most crucial functions: advocating for Emergency Department patients, and advocating for Emergency Physicians.

The excuses offered by Dr Gardner for ACEP's reticence to take a stand are fairly lame.  Specifically, she writes that this has been a continually shifting landscape for the last years, which is true enough, and she cites the "deep divisions" in opinion regarding the reforms, and instead offers up a vague set of principles which ACEP had previously laid out as its priorities in any reform bill.

Which would be fine if the House was set to vote tomorrow on a vague set of principles.  We'd be all over that!  But for the actual reforms, sorry, ACEP couldn't figure out, as an organization, whether it should support or oppose it.  This is despite the fact that the broad outlines of reform have been perfectly visible for ages.

Let me be clear: I wish ACEP had lined up with the AMA and the other medical societies like the AAFP, the ACP, and the AAP in favor of reform, but that's because I support the reforms.  But it would have been perfectly legitimate had the ACEP Council or Board joined the folks at the Texas Medical Association, the American College of Surgeons, or the Congress of Neurological Surgeons in their unapologetic opposition to the reform. 

I remember that in Dante's Inferno -- greatest piece of 14th-century Italian poetry I ever read -- there was a special place in Hell for the Uncommitted, for those souls who, in life, couldn't decide whether they supported good or evil.  (Technically, they are outside the gates of Hell.  Their punishment is to eternally pursue a banner while pursued by wasps and hornets that continually sting them while maggots and other such insects drink their blood and tears.  Nice!)  It's sad to see an important organization like ACEP fall into this category of the pusillanimous and the timid when faced with the most important piece of health care legislation in our professional lifetimes.

And remember, ACEP does not pretend that it has no role in politics.  They aggressively market their political action committee, NEMPAC, with the goal of being the most influential specialty medical society.  But when they come to me and ask for money, I will ask them, "where were you when health care reform was on the table?  Why should I contribute my hard-earned dollars to an organization so feckless that it couldn't even figure out its position on the bill that will impact our specialty more than any other law in three decades?"  An advocacy organization that can't figure out what to advocate for (or against) is pretty useless.

And make no mistake, this bill has huge implications for Emergency Medicine.  ER docs provide care for 20 million patients annually who have no insurance; the cost of providing care to the uninsured for EACH ER DOC is $125,000 per year in unreimbursed care.  This bill promises to expand insurance to 31 million Americans -- their care in the ER will now be funded.  This will reduce our need to cost shift to private insurers, this will provide much-needed capital to expand overburdened ERs, and this will support recruitment and retention of skilled ER docs in underserved areas.  Moreover, this reform will invest in community health centers and reimbursement for primary care, to give patients options to receive non-urgent care and follow-up care in settings more appropriate than the ER.

Yet ACEP, historically dedicated to the parochial interests of EM, can't decide whether this legislation is good for Emergency Department patients and physicians. 

It's true that this has been a divisive debate, and there are many of us with strong opinions.  However, my experience is that most ER docs that I personally know do have a great degree of confusion about the reforms proposed.  Most ER docs (shockingly) don't take time on their day off to read the CBO scores and delve into the policy details.  This is why we have a professional society -- this is why we have leaders.  We rely on their expertise, we rely on their efforts to prise apart the statutes and the funding and come to a conclusion and lead the organization in a chosen direction.  I don't expect unanimity, and in fact for this issue I would expect a lively debate within the ACEP Council before a decision was reached -- and consensus may indeed have been elusive.  But this is why we have elections and why there are processes for reaching positions, and had Dr Gardner the courage to follow these processes to a resolution, ACEP would have been in a position to influence the national debate that it now reaching its conclusion.

Dr Angela Gardner and the other leaders of ACEP have failed in this obligation to their constituents.


  1. Of course you don't think maybe they took this position because they were smart enough to realize this is a zero sum issue in the first place?

  2. Er, are you a member of the ACEP? Then it's your fault too. If you don't the leadership vote them out.

  3. I meant if you don't like the leadership...

  4. The current CBO report says that by 2019 we'll have 23M without insurance, and today we have around 45M, so the problem cuts roughly in half. But it's not anywhere close to going away.

    The uninsured don't visit the ER with more frequency that the insured (see Economist article), it's just that when they do visit they don't/can't pay.

    These same folks will not pay for insurance either. They will be subsidized.

    And so the costs savings that you believe we might see are not savings at all, but instead they will just be shifted elsewhere.

  5. As I recall, resolutions to support universal health care came up at least twice in the past two years at ACEP and were voted down both times. Our leadership at ACEP, like our congressional representatives are representatives and are supposed to represent the will of their constituents.

  6. Be careful what you wish for.
    Unintended consequences are so highly likely with the 2600p bill, that medicaid like restrictions on EM care are a likely consequence of expanding demand, shrinking primary care and exploding deficits. What is the consequence of reducing medicare budgets by $50B/yr while tens of millions of boomers start retiring over next decade? Medicare just went into the red this year because of decreased funding 2d to higher unemployment,
    for the first time ever.

  7. Good points, all. Yes, I am an ACEP member (and longtime advocate). Yes, I will remember this failure when I consider choosing the future leadership. Mostly I am disappointed in the current leaders; I had thought better of them.

    Re: uninsured: true; they visit the ER in line wiht insured folks. However, the cost controls are real (IMAC, CER, etc) although they will take a long time to cone to fruition.

    Re: Mediare cuts: bear in mind that these are reductions in payments to private insurers administering Medicare Advantage plans (who get about 12% more per beneficiary than the actual cost of insurance), so they are already an excess cost on medicare which needed to be cut. It's not a general "cut in medicare," ust an end to the private insueres' subsidies.


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